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

Welcome to the Huberman Lab Podcast,

where we discuss science

and science-based tools for everyday life.

I’m Andrew Huberman,

and I’m a professor of neurobiology and ophthalmology

at Stanford School of Medicine.

Today, my guest is Dr. Paul Conte.

Dr. Conte 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. Conte 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. Conte 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. Conte 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. Conte 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 Conte.

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.


How should we define trauma?

We all have hard experiences.

Some of them we might ruminate on more than others,

but what is trauma?

I think 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,

and then leaves us different as we move forward.

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

And then that change is 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 microtraumas?

What are macrotraumas?


I think traumas that we might categorize

as disappointments, right?

Or things that 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 it 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, 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,

it often leads us to bury it, 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 wanna stay away from one another and isolate, right?

But with the trauma epidemic,

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 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 it 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.

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 sort 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 it anchors, as I talk about this,

the example I’ll use at times

the example of my own life,

where when I was much younger in my early 20s,

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?

Because 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, you thought that you could be effective

and you could make your way in the world.

And 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 options are all gone.

And 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?

Well, my reflexes to that were 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,

you know, everything you’re telling me is that

in the end, that’s not adaptive.

Why would we be built that way?

So that’s the first question.

And then the second question is,

how should we conceptualize guilt and shame?

You know, I think 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 don’t serve us well.

So maybe in that order or in reverse order,

you know, 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 mean, 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,

you know, 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, you know, if you ate a new food

and got really, really sick,

it’s like, you better remember that, right?

You know, if you see someone from the group of people,

you know, 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 if 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 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.

So then 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, you know,

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, like look at the news for news.

Anything going on I need to know, right?

But what are people doing is they’re 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, immigrant 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?

You know, 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, you know,

years and years and decades and decades.

It brings so much misery and suffering,

and at times it brings death.

If you think about 100,000 overdose deaths

in this country in a year, 100,000.

I mean, where is so much of that arising from?

As 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 is tormented by it.

And now there’s a pull for these drugs

or sometimes medicines to soothe.

So, you know, the opiates that were given

after a minor surgery, right,

are like, okay, yeah, they help the pain

from 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.

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,

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 to stuff it away.

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 on a 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

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

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

in an attempt to solve it.

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.

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

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 surface of it, it’s like, it makes no sense.

But then if we think, well,

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?

We’re logical, and ultimately everything in us

can just boil down to logic.

And if we think about it enough,

we’re gonna understand how to make the right decisions,

which is completely not true, right?

The limbic system, the emotion system, so to speak,

inside of us always trumps 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 I’ll sort of 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 said,

we’re starting to do therapy, right?

And the person will say, gosh, like I know,

look, you just can’t help me, right?

I mean, my last seven relationships have been abusive, right?

And I’ll say back something sometimes like,

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

because 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 the light bulb that goes off,

like I have not had seven different abusive relationships.

I have had one that I’ve 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,

you know, like a medical abscess inside a person,

you know, a walled off infection inside the body,

this is the same concept in the brain.

Then of course the limbic 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, it’s, 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 it the person who was abused

or the person who was abusing, right?

And we can get at 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.

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 then we can take away its power.

I keep hearing in this narrative

that so much of our reflexive response to trauma,

both emotional and the repetition compulsion

in terms of behaviors,

is about some very deep attempt to change the past.


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 try and change the past

is remarkable and eerie and maladaptive,

it sounds like.

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 just 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 state,

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 what to do with it.

And I’d love to hear a,

maybe even just a top contour prescriptive

of what does one do?

I’ll even just put myself in it.

What do I do?

So I’m feeling upset about something.

I feel like my options are healthy catharsis.

I can tell the story, feel it.

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, et cetera.

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’s perhaps a re-emergence of the arousal.

The arousal can become greater.

I mean, 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 multi-dimensional question,

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 hypervigilance, 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,

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,

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 so afraid so often

of looking at the trauma that has changed us,

that we’ll look anywhere but at that, right?

So it’s like it’s 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 the 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 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, you know, 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?

Like that, you know, 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, you know,

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?

We 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, that’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.

You know, we can’t grieve

if there’s guilt and shame inside of us.

It just blocks grief, right?

We have to, it 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,

guilt and shame, 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.

But instead, our system defaults to guilt, shame,

and trying to hide it.

And this repetition compulsion of placing us back

into things similar to those traumas,

or even maybe even worse traumas,

in an attempt to resolve it.

It’s like the most maladaptive wiring diagram

I could possibly think of.

Emotional and presumably physiological wiring diagram.

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 whole system seems completely backwards.

And I’m chuckling as I said, it’s 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 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,

where the person will have the same relationship

with seven different, the 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.

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.


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

Is there benefit to taking a walk

and thinking about these things,

breaking down and crying if that’s what’s necessary,

or feeling angry 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 that is itself a form

of the repetition compulsion,

because you’re feeling it all over again.

You’re not seeking out something to evoke that feeling.

So I realize this is a little bit of a circular argument

or question, but I think it’s one that I really struggle

with in trying to parse all the outcome-based

therapies that I hear about

and the recommendations that people make.

I mean, how should we conceptualize this?

Something happens, it 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 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,

how do we do that in a way that isn’t re-traumatizing

ourself in a major way or in a minor way?

How do we know where we are in that landscape?


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

Like I think of a certain person who really loves music.

And then at some point in our therapy work,

I learned that she was taking long drives,

but the radio wasn’t on.

And I was like, well, 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 said, I’m saying it for a point of exaggeration,

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, 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?

There’s a wait, 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 it’s 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 by the trauma.

So I tell the story sometimes of a person

who 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?

And get out there that after trauma,

they saw the award with a 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 there’s going to be the greatest achievement of 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 you’re talking about miraculous in a negative way,

also change that going backward, right?

And when we can really look at like,

where did that come from?

And we can start unraveling it, it changes.

So in those cases,

often it’s helpful to have a good therapist.

It’s not always necessary.

And it’s 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.

You know, 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.

And then when you take a trauma history,

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

Like that’s when the drug use started shortly 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 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

that’s going to upset me.

And for the longest time, I would 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, anger is such an attractive emotional force

and it’s an attractant.

It’s not attractive, we don’t like it.

And yet oftentimes anger is a great way

to replace feeling something else,

feeling sad or having to come up

or to do work or to do something useful.

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

That was one idea.

The other idea was in imagining kind of worst outcomes,

then actually that relationship

could actually seem a lot better in reality.

It’s almost like creating this negative contrast.

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 the three factors,

punishment, avoidance, and control, right?

So the trauma inside of us that makes a guilt and shame

so often, so often leads to a desire to punish oneself,


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 punish them, right?

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

We punish them.

And so 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, do better by hurting us more

for the things that we couldn’t

and shouldn’t have been able to,

weren’t expected to be 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.

You know, anger, it can be more gratifying

than certainly than guilt or shame.

Although guilt and 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?

Because 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 the kind of the sequelae.

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 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.

And just as a question of how much worse

and in what direction.


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.


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 as a useful tool.

Maybe you 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.


If I could add something to what you just said

before the question,

that we have these short-term coping mechanisms in us.

And in a way it makes sense.

We find ourselves in just terrible situations,

then a short-term coping mechanism

can get us through them.

So our brains are built that way

and that’s part of survival too.

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,

the anger is short-term soothing

at the expense of long-term change, right?

And that’s where addictive pathways come into play.

And that’s where again,

how we’re built evolutionarily for survival

doesn’t help us in the way humans have evolved.

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 a 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?

It’s that, whether it’s words

or whether we’re writing that’s so important.

So I think for journaling, it depends on the person.

You know, 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 look different than everyone else,

right, or I acted different from everyone else.

Wow, you know, to actually see that written out,

it’s, you know, 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 to, that’s where this came from, right?

That’s why I’m saying this.

It’s those kinds of revelations that we can have

through, again, the written or spoken word.

And I think, again, that involves a trusted other,

you know, or writing.

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, you know,

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, you know, 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 to like finding the right therapist,

right, which is also part of your question.

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 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 or 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 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

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.

So in a way, it was a transformation

of something negative inside of me

into a functionality in the world

that was actually very rewarding and beneficial.

And yet in describing it,

I can immediately see how it would be wonderful

if I could source from something else.

And yet I, you can imagine,

and I can imagine how one would be reluctant,

maybe even terrified of giving up that source.

It’s a fuel.

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.

And so people are reluctant to give up this fuel

because 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,

because 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.

Maybe, it was on this sentence,

it was maybe you could actually be much more effective.

Maybe you could be 10 times the better brother.

Maybe you could have 10 times

more insider work capacity, et cetera.

So it’s on that hint of a promise

that 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.

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 brother,

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?

We know 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,


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 would 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.


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.

You know, there’s this person,

you might want to work with them.

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, you know, for instance,

I’ve heard this from listeners,

although I’m definitely not talking about myself here

in cloaking something.

Some people will say, you know,

I want to work with a somatic therapist

because I’ve actually heard someone say,

I think in feels, they, you know,

I feel stuff in my body.

So I want to work with someone

who can really acknowledge that.

Or someone else will say, you know,

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.

You know, 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

because of these kind of predispositions.

Right, right.

Well, there’s a lot of data about this over the years

that 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’s paying attention, right?

It’s trust, it’s a back and forth.

It’s like, yeah, even though I’m doing,

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,

if someone, a therapist is 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 think about that

is the different modalities.

It doesn’t actually tell us that,

oh, the modality is irrelevant.

I think that’s not true.

I think that good therapists are not pigeonholed

by a certain modality.

They may, you know, come at the world

largely through a psychodynamic,

or a CBT, or a DBT lens,

or there’s lots of different ways to do therapy.

But when you really talk to those people,

really good experienced therapists,

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

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

You know, 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 a winning combination.

Great, so people should perhaps try a few therapists

and maybe have a session or two or three

to see if the rapport feels like it’s taking root.

Is that, do I 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 people have a therapist

or they call 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 know, 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 like, 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,

oh, 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 doing it, but to say, right,

that’s how I’m going to be helped.

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

you know, 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.


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, et cetera.

But 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, et cetera.

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 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 gonna be, I show up early,

I sit, I calm myself, I meditate a little bit.

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

For other people, they just 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 I think 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, I think sometimes it evolves

and sometimes we talk about it, but it varies so much.

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 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,

because 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.

You know, 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 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 we’ve found that the benefits of doing that are immense.

It’s like, I’d say a year’s worth of therapy consolidated.

And you just take, well, 30 hours,

let’s say, you know, 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, you know,

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.

There’s something now it’s like, whoa,

something 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 gotta go more, right?

Because I gotta do that processing

so I can get to the place that I am,

which is not that the trauma has no impact on me, right?

It’s that the impact is much less

than it was before the therapy.

And that I most often, 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 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 and 30 hours a week in one week?

Right, right.

It’s usually a person who is really distressed by something,

whether 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 gotta stop having panic attacks.

Like I need help, right?

But it’s usually some crisis point

with the idea of crisis and the meaning of,

okay, something comes to a head

and after it, things are gonna be different, right?

Not a crisis and things are gonna be negative afterwards,

but a point where then that cognitive flexibility

comes to the fore of like,

wait, 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 wanna, I wanna look at myself,

wanna 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 it looks 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

because 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?

Because 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 I, do I feel helped, right?

Am I, in some ways, even like happy

that I’m not feeling helped

because 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

because it’s hard sometimes for a person to say,

oh, I need more therapy

because 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 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,

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?

There could be, but again, it depends by person

because 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 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 not the common situation, right?

It’s more often that person has to acknowledge,

like the example of like, I was sexually abused

and have to acknowledge that 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,

you know, they’re clergy members.

Even if one isn’t affiliated with an organized religion,

you could probably go places

and get a 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?

Because we could probably go find someone,

but we need to kind of take that in pieces.

So there’s some risk to 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, you know,

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, you know, 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.

You’re welcome.

So we’ve been talking a lot about talking.

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




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.

And 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, you know,

wrap our arms around all of that

as a way of wading into this drug question

and just address, you know,

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 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.


I mean, I would first comment that, right,

there aren’t tests for these things.

And I think the test for metabolites,

I mean, things are so different, you know,

by the time what we’re talking about has been metabolized,

you know, often to some very significant extent,

left the brain, now it’s in the peripheral blood

that we really don’t learn from that.

And I think that we tend to over-utilize medicines

in this country because we have a healthcare system

that often it’s so based on throughput

that we want to polish the hood

when there’s a problem in the engine, right?

So we over-utilize medicines often as an endpoint, 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 it’s for that 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 there are two steps to it, right?

The first assessment step is,

is there a diagnosis 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 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 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 gonna go,

now you’re gonna do something difficult,

or you’re gonna bring that trauma

or the stressors to the surface,

and you’re gonna process,

and you’re gonna 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 hypervigilance

and avoidance, right, 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 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,

to even generate the understanding.

So then medicines get thrown at 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?

They may go, why is five times more

is a lot more medicine, right?

And 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 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,

the nurse practitioners,

the people who are practicing in that way,

because oftentimes there is no choice, right?

If they’re working in a healthcare system

that the standard is highly spaced

or spaced apart 15 minute visits,

what alternative is there, right?

But to look at, okay, I’m gonna 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 its short-term talk about,

you know, we talk about short-term response, right?

There are short-term soothing

at the expense of long-term health.

And I think that is the metaphor

that applies to our healthcare system, right?

Where if we are gonna try and treat a symptom

in a short term, we’re gonna do it in a 15 minute visit,

that we’re gonna do it in a way

that maybe it soothes the 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,

you know, 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,

treating people and taking care of people

because it’s more human time,

but ultimately 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 gotta 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 someone who’s 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 don’t know 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, you know, I’m old enough to remember the book,

Listening to Prozac, and I remember when Prozac

and things like it first started showing up

and the excitement.

And then nowadays I hear more about the problems

with all these drugs, you know?

And maybe that’s just because I have arms

in both the scientific,

but also in the kind of wellness community

where people think a lot about behavioral change.

Fortunately, I think that they do that.

But of course, these drugs, as you mentioned,

can have enormous utility as well.

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.

Because I could imagine, you know,

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,

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,

or you’re not going to take anything.

I mean, that just seems to,

life doesn’t, does life have to work that way?


Is there a short-term use that can be effective?

Yeah, absolutely, yes.

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 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 over-invest 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,

because sometimes that’s necessary,

but absolutely for the shorter term, I mean, absolutely.

If we thought of Prozac and those kinds of medicines,

not as, oh, they’re antidepressants.

We thought, look, what they do is

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 in 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, oh, that person is a,

and a lot of times there’ll be a number, right?

The number is the diagnosis

and that number gets this medicine.

And like, 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,

that they need more latitude to help us.

So 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 payoff of that.

What is your thought about anxiety and ADHD

as a separate phenomenon 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 in or taking

Ritalin, Adderall, Modafinil, Armodafinil, or Vyvanse

because they seem to struggle focusing without it,

or, and I don’t know,

because 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.

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.

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 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?


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.

Like, 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 certainly trauma,

the problems that trauma spins off can affect attention.

So, 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 don’t know, middle school students or something,

they would probably say,

you just told the story of a person

with a rock in their shoe,

which is the story that I was actually telling, right?

But several people I was talking to,

these are 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 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?

Because 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 catch-all diagnosis

because there’s, in a sense,

something to do for it, in quotes, 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,

you’re 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,

upwards of 75% of college students

use semi-regularly these drugs off,

not by prescription, just to study and to learn.

I can imagine sleep issues because these are stimulants.

What sorts of other issues can they create for people?

Problems that they can create?

I think a touchstone maybe

that’s running through our conversation

is prioritizing the short-term benefit

over solving a long-term problem,

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,

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 risk to that.

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 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, then 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.

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?

Which is part of my whole theme about trauma, right?

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

Well, 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,

person will just say, oh, I’m just using it to study.

I’m using it to work more.

That’s not without its high level of risk.

What are your thoughts on cannabis?

I’ve said it many times on this podcast

before I’ll say it again.

I feel fortunate that I’ve never really been attracted

to alcohol or drugs of any kind

in so much so that if all the alcohol

and all the marijuana

and all the cocaine and amphetamine disappeared,

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

And I feel lucky in that way

because I know a lot of people feel an attraction

to these things as almost a gravitational force

from their first drink, they just feel.

I once heard it described in this,

I think it was in Guston 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.

But at the same time,

you could really understand

why someone would be drawn to that.

So cannabis nowadays is legal

or decriminalized in many areas of the US.

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?


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,

it approaches zero, right?

The alcohol for coping is just never good.

And there’s an additional risk factor

that there are 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 a 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 had West in Northern Europe.

So we understand that 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 neuropharmacology of it,

like how is this really working in the brain?

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 use cannabis

before watching a movie with friends or something, right?

And I think, okay, I think why people are doing that

is because our cognitive spectrum narrows.

And then instead of worrying about that thing at work

or that relationship issue, one can just be present, right?

For it gates out other attentional intrusions, right?

So in some ways, I mean, I’ve absolutely seen it

be helpful to people.

I mean, it’s been legalized in Oregon,

which is where I spend a lot of my time,

and it’s not where all of my practice is.

But what I have seen is it is at times helpful,

say around sleep, right?

Because a person can gate out other intrusive thoughts

and they can just relax and go to sleep.

But there can be another side of that too,

that at higher levels of distress,

at higher levels of tension,

what it can do is narrow the focus of cognition

to the thing that is negative, right?

So the idea that, oh, this is a treatment for depression,

anxiety, trauma is not true, right?

Can it be helpful under certain circumstances?

Like, I think the answer to that is yeah.

I mean, I know the answer to that is yes,

because I’ve seen it play out clinically that way,

but it can also be harmful too.

So there again, like anything that has any power,

power to influence our brains,

we want to be thoughtful and careful about it.

I mean, do I think that it’s safer than alcohol?


I mean, I think we so clearly see that.

Does that mean it was just uniformly safe?

No, right?

So we want to be respectful of anything

that can change how our brain is working.

And I think that includes, certainly includes alcohol,

and I think it certainly includes cannabis too.

I’d love to talk about psychedelics for two reasons.

One, there seems to be a tremendous amount of interest

in psychedelics as a therapeutic clinical tool.

I know there’s also recreational use,

and I’ll just preface all this by saying that my stance is

we absolutely know for sure

that these are controlled substances.

They’re illegal to possess, sell, or use

in most of the country.

There are a few areas where they are decriminalized.

And psychedelics is a broad category, of course,

and we can touch on some of the different ones.

But whereas five years or so,

five years ago or so,

I was truly afraid to say the word psychedelics

in any kind of public venue.

There are laboratories at Stanford

working on ketamine, psilocybin, MDMA,

mostly in animal models.

There’s terrific work going on

at Johns Hopkins School of Medicine

and Matthew Johnson’s lab and others

looking at the clinical applications,

mainly of high-dose psilocybin and LSD.

There’s the MAPS trials with MDMA.

So nowadays it’s safe for an academic like me

to say the word psychedelics,

and I’d love to approach this question of psychedelics

from a place of true exploration and curiosity,

but with the preface that we’re talking about

this in a legal clinical setting.

And the legality is something that’s now in process.

I don’t think it’s completed,

but that’s my understanding.

But there are trials.

You can go to and put in MDMA

and you’ll see a bunch of clinical trials

that are happening in the recruiting subjects.

So I think it’s safe to have the conversation now,

and I’d love your thoughts about psychedelics.

Maybe we could start with psilocybin and LSD

as a broad category of drugs

that at least my understanding is they touch on

mainly the serotonin system,

some specific receptor activation and modulation,

tend to change notions of space and time,

adjust internal state.

Maybe we could start there

and then maybe venture into some of the other ones.

So what are your thoughts on these drugs

for a therapeutic potential,

also potential hazards, et cetera?

Yeah, I think if we look at the true psychedelics,

so psilocybin and LSD, because ketamine and MDMA,

they’re different categories of medicine.

They’re these sort of novel tools to bring to bear.

But if we start with psilocybin, LSD, true psychedelics,

I think why they have gained so much momentum

over the last several years

is because the data coming from the labs

and the academic centers is so powerfully positive.

And as someone who’s,

I’m interested in anything that’s potentially helpful,

and I want to learn and understand that

because a lot of things that are potentially helpful,

you go and look at the data

and you see that that’s not helpful or that’s harmful.

I think what we have seen with psychedelics

is that they’re so helpful,

and the trials are bearing that out.

And of course, these are used in professional hands

and with the right kind of guidance

or extremely powerful tools,

but used in the right way

by someone who knows how to utilize them

in the right set and setting

can have an immense positive impact.

And that’s why I think that the thought is there

across people and more and more people feel comfortable

saying it and talking about it.

I mean, we’re in the state of Oregon now

where the thought is we’re moving towards legalization

of psilocybin early in 2023.

And it’s part of the new data, right?

And how it meshes with the older data, right?

How it meshes with data from the 60s and 70s

that showed such a strong, powerful impact

of these medicines.

And I have a whole set of thoughts

about what’s happening there.

And they’re just, they’re conjectures, right?

But my read of, you know,

as best I can try and understand the neuroscience

and the clinical applicability and the changes

is, you know, what happens is we see less communication

or less chatter in the outer parts of the brain, right?

In the outer parts of the cortex.

And I think that as human beings,

we sort of glorify the parts of the brain

that only we have.

I mean, certainly in my growing up, right?

I mean, what did I learn?

Even if you think about like learning about the brain

in high school, right?

I learned that like, wow, we’re great as humans

because we have language and other animals don’t

and we can use tools and like, aren’t we so great

because we have this part of the brain

that other animals don’t and it lets us function, right?

Okay, there’s some truth to that, right?

That we can do things others can’t do,

but we get lost often in the outer parts of the cortex,

which I think are about survival, right?

So we come back to the things you and I talked about

early on of like, why are these trauma mechanisms in us?

Right, so much of what’s going on in our brains

is about survival.

And I think living, so to speak, in the cortex, right?

In the outer part of the brain

is consistent with a focus on survival.

So if you think that’s where language is,

that’s where vision is, that’s where executive function is.

So planning and task execution.

So, so much of that is about making our way

in the world around us.

So we tend to glorify that and think, well,

that’s in a sense where our existence is, right?

And I believe that is not true, right?

And again, can I say that for sure?

Of course not, right?

But my read of 20 years of doing clinical work

and thinking about all sorts of medicines

and thinking about the psychedelics in a lot of depth,

I think that what they do is they take us

out of the cortex, right?

Because that’s where we run into these problems.

That’s where we bounce things over and over again,

that the distress centers deep in our brain,

in the brainstem, kind of ally

with the outer parts of the cortex.

And they say, right, we’re in distress,

we wanna stay alive.

Often a lot of us have had trauma

that makes these changes in the brain.

And then we’re thinking all the time,

like what would I do if there were war?

What would I do if there’s civil war,

if someone bombs us?

What will I do if the economy collapses, right?

What will I do if somebody gets sick?

We’re thinking all this future projection

that is all coming from a place of fear, right?

It’s all coming from a desire to think about things

and control the future with this part of the brain

that is so uniquely human, right?

And I think when we take the neurotransmission

out of those places, right,

and we set it in a part of the brain

and say the insular cortex, right?

The parts of the brain that are sort of in the middle,

right, which I think, I believe,

is where our humanness really is.

So the psychedelics make there be less chatter,

communication in these other parts of the brain,

and then we become seated in the part of the brain

that I believe is most about our experience

of true humanness,

which is why when you read about people

who have experiences, and I’ve heard about them,

people talk to me about this, right?

They’ve utilized it, they talk with me.

So whether it’s someone telling me their story

or it’s coming from research data,

you know, it’s why people can sort of see with clarity

that, oh, that trauma, like that thing is not my fault,

right, like we feel a sense of compassion for ourselves.

We relieve ourselves, release ourselves from guilt

and it’s like, why is this so helpful to people?

And I think it’s because it can do

what we are trying to get at in good therapy,

but it can really catalyze that

by just putting a person in that part of the brain

that can see it for what it is

without all that chatter in the cortex

about how you gotta think it’s your fault

or you won’t avoid it again

and that makes the repetition compulsion.

How do I think ahead to the next thing that might happen

and what else bad might happen?

I mean, we don’t get anywhere doing that.

And I think where we get somewhere

is when we seed ourselves deeper in the brain,

which I think we do if we’re like doing really good therapy

and we’re in the deep parts of the brain,

but these psychedelics and medicinal value,

I believe is putting us in that part of the brain

where a person can really find truth.

And that’s why I think that it’s come so far

in these few years

because I think that is very clinically evident

and I think we’re gonna see more and more

of the value of that

and how what the psychedelics do can become,

I believe, a heuristic for understanding like,

wait, how are our brains really functioning

and what are the parts that really matter

to our experience of being human?

It’s those parts of the brain, right?

The deep parts of the brain,

the insular cortex and the areas around it

that say light up when a person has

an experience of spiritual ecstasy

or an experience of connection with another person, right?

So we kind of have these telltale markers

that something is going on there

that’s very important and very special.

And I think we’re more attracted

to the outer parts of the brain

in part because they’re easier to study, right?

I mean, as you know better than I do,

we started studying the brain through lesion studies, right?

Because it’s easier to see if a person got hurt

in this part of the brain

or had a stroke in that part of the brain, what changes.

So we look at the cortex because one, it’s easier to study

and we tend to glorify it.

And I think that has been misguided.

And I think that we’re learning

about how that’s been misguided

through the study of these novel modalities

from Western perspectives,

but of course they’ve been used for a long, long time

in other cultures, but novel from our perspective.

Yeah, I’m fascinated by this idea

that in these middle brain structures

is where our humanity lies.

And as you said, I also wonder whether or not

other animals experience life more from that orientation

with less chatter.

We can only guess, but the dog lover

and being in the presence of animals

that seem to just be present in what’s happening

in their immediate environment,

not too much anticipation.

Right, I mean, what you’re talking about is sentience

is important and sentience is extremely important, right?

And if we’re going to overvalue say language,

then I think we undervalue sentience, right?

Which is why I think we tend to undervalue animals, right?

And their suffering because, well,

they’re not saying anything about it, right?

And they’re not writing about it.

So, okay, it’s easy to ignore.

And we think about, again, the hubris of that, right?

That, oh, because we can think and talk and write,

like we must be feeling more

than species that don’t do that.

I mean, I think that that is so true

and that we’re gonna understand more

about sentience in other species

and how that’s at the core of existence.

And my hope would be that we value more humans

and animals, right,

through the evolution of that understanding.

The hallucinations that accompany psychedelics

like LSD and psilocybin

have such an attractive force to them

as a concept and as an experience.

And so I think most often when people hear hallucinogens,

they think in psychedelics, they think about hallucinating.

It makes sense why they would.

But what’s so interesting to me is nothing in your answer

about psychedelics, psilocybin and LSD

focused on hallucinations per se.

It was more about feeling states, accessing a feeling state

or a relation to an event or to a person or to oneself.

Maybe even I caught hints of maybe even empathy for oneself

for the first time.

None of that had to do with seeing sounds

or hearing colors and these kind of cliche statements

about hallucinations.

So I am aware of laboratories,

one at University of California Davis in particular,

but a few others that are trying to generate

chemical variants of psychedelics

that lack the hallucinogenic properties,

but maintain these other properties as therapeutic tools.

And as I say that,

I realize that people in the psychedelic community

are probably thinking, oh, that’s horrible.

That’s the dismantling of the core thing.

But the simple question is,

do you think the hallucinations are valuable for anything?

And I think we’re really getting into the philosophical,

the ontological, right?

There’s this sort of trying to understand being, right?

And I don’t claim to know the answer to that.

I think that at times it seems like the hallucinations

have a metaphorical or a symbolic way of being helpful,


Because people will come to understand things

that they hold dear and true after the experience, right?

That often, not always,

come through the lens of the hallucination.

So are the hallucinations necessary?

Are those hallucinations sometimes important, sometimes not?

I mean, I think we don’t understand that.

And I think we want to be respectful

of the sort of mystery of that.

But what I think is fascinating is,

you think about substance abuse and what that means is,

well, one aspect of that is that a person

has experiences, thoughts, conceptions of self in the world

with the substance that without the substance,

they know are wrong, right?

People talk about liquid courage, right?

And okay, I feel better about myself and I feel courageous

because I’ve had a couple of drinks.

Now, after that, I feel normal about myself

and that was false, right?

And we see that.

That’s part of what substance intoxication means, right?

But what we see with the psychedelic medicines

is something that’s incredibly different, right?

That people are having experiences that are so de-linked

from our normal experience of reality.

And then when they come in a sense back online,

with in a normal cognitive way,

they realize like, wow, now I’m applying

all those mechanisms of trying to understand truth

and to that and what I see is that it’s true.

And wow, it’s true.

Like, I mean, we hear that all the time,

which tells me, hey, something different is going on there.

And of course these are powerful tools.

So misused, like very bad things can happen.

But you think about the clinical utility

and what does it mean that so many people

change for the healthier or even change their lives

after an experience because it so resonates as like,

oh, now I understand something that’s true.

And it’s not something bizarre.

It’s like, I wasn’t responsible for being raped that time.

Or, you know, I’m not less than

even though my sexuality or my gender identity

is different from some silly binary concept, right?

Like people kind of can often get it

and they feel differently about themselves

and guilt and shame are impacted.

So I think we’re likely to see

that they are powerful anti-trauma mechanisms,

again, used clinically in the right hands.

And I think that we’re also gonna see

that they’re a heuristic for understanding our brain

that goes against what I see

as some of the reflexive hubris of,

well, the outer parts must be the best

because that’s what makes us human

and other animals don’t have it

and we’re better because we’re human.

I mean, it makes no sense, you know?

I’d like to talk about MDMA.

And I’ll preface this by saying I was a participant,

actually, technically, I’m still a participant

in a clinical trial.

So I have experience of doing it twice.

The trial involves three separate dosings of this.

I was reluctant to do it outside of a clinical trial

most because I was aware

there can be some cardiac effects

and I liked the idea there’d be a clinician on hand.

And I’ll just say that I found the experiences

to be profound, beneficial,

and very different from one session to the next.

The first one felt a whole collection of ideas

and relational things came up

that felt very powerful and transformative.

And I do think that I learned there.

I exported a number of things.

My particular experience isn’t relevant here,

but the second time I expected it to be the same way

and it was very mellow and relaxing

and was deeply tied to kind of notions of acceptance.

So there weren’t all these revelations and wow, new insights.

It was very much about sort of grounding

into a kind of a calmer state.

So I have the personal experience of benefiting from these

in ways that I think still benefit me

and was very struck by the power of MDMA.

And my very crude understanding of the pharmacology

and the state that is being under MDMA

is that it encourages or increases

dopaminergic transmission,

but also serotonergic transmission,

which is to my knowledge,

a kind of a rare state for the brain to be in.

That typically it’s more of a seesaw

of dopaminergic drive towards external goals

or more serotonergic drive towards more placidity

or comfort with what one already has.

And so with both those systems amplified,

the only way I can describe it subjectively

is that everything sort of funneled back in

and it was almost like a pursuit of inner landscape.

And I can only imagine what it would be like

in the context of doing this with somebody else,

also taking MDMA.

I have no idea what that’s like.

That’s my report of the experience.

I know that the experience can vary.

What are your thoughts about the chemistry

and what sorts of states do you think MDMA is creating

that can explain why it’s a useful therapeutic tool

in some cases and what sorts of cases those might be?

Sure, sure.

To clarify, I think part of what we’re starting with

is like this is very different than the psychedelics, right?

Which are seeding our consciousness

in these deep centers of the brain, right?

Whereas what MDMA is doing is sort of flooding

with positive neurotransmitters, right?

In certain parts of the brain.

And I think what that creates

is a greater permissiveness inside

to entertain or approach different things, right?

So I think where we see it’s tremend,

my read of the data is around potentially,

and we’re seeing in some of the trials, right?

Tremendous benefit for trauma, right?

And you think about what we were talking about earlier,

how this reflexive guilt, shame,

hypervigilance, avoidance, right?

And when these systems are flooded

with these neurotransmitters,

it’s more permissive to think about that, right?

And to think about that without, again,

all the chatter of that’s your fault,

or you’re never gonna get anywhere because of that,

or you know what that means, right?

They can kind of go away and then we can think about it

in a way that isn’t through the lens of fear, right?

And I think that’s the power there

is that it’s permissive of approaching something

or contemplating something, you know, a different,

a novelty, as we talk about a de novo approach.

And I think that’s also why the experience can vary

because you could also see how

if you’re not thinking about something, right?

So there’s not a clinical guidance to it.

You could be in a state where like,

I just feel good, right?

And I’m thinking about good things

and like that can feel good, right?

But that’s not necessarily problem solving, right?

So the clinical guidance says,

let’s take that state and do something with it, right?

Now that you’re in this state, let’s, hey,

let’s make cable, the sun is shining, right?

You’re in a state where we can look at things

that are traumatic, right?

We can approach them from a de novo perspective.

And I think it’s part,

I think that explains why you had these different experiences

from one to the other,

because your brain is just in a state

that’s conducive to something, right?

But if there’s not the mechanism to have that thing happen,

like conducive to something therapeutic,

then you might go there on your own

or you might just be in a state

where you have a sense of wellbeing and you sit with that.

Which sort of seems like a waste to me.

I mean, this is what I tell people

when they ask about MDMA.

I said, at least from my experience,

that the potential hazard there

is that in that very high dopaminergic, serotonergic state,

there were moments where I felt like I could get excited

about any one specific concept

that I might even just think about, for instance,

water and how nourishing it is

and really just go down the path of water

and the world and all the water.

And you can, you’re in a state

that is very prone to suggestion, internal suggestion.

And so the guidance turned out,

the guidance from the clinician turned out

to be immensely valuable

in allowing me to go into my own head for bits of time,

but then also to resurface and share and exchange

in a way that to,

I’m trying to really get something out of it

that was useful and that I could export.

Because of course, water is wonderful,

but I’m not really interested

in growing my relationship to water.

And I really felt like I could understand for the,

I never went to raves or anything growing up.

I never did MDMA recreationally,

but I understood for the first time

how people could get really attached to an environment

and feel connected to things,

because I think with all that serotonin,

you just feel connected to everything around you.

So I think it’s a slippery slope there.

And I don’t know what the future

of the clinical use of MDMA looks like,

but I would hope that whoever’s thinking about

guiding these sessions is really thinking carefully

also about evolving the practice

to help people really move through in a sequential way

so they can leave with something valuable.

Yes, 100%, 100%.

These are such powerful tools.

And again, if they’re powerful tools

and we’re using them without respect for them, right?

Without clinical guidance, we incur risk, right?

I mean, getting obsessed with water,

well, and it probably isn’t gonna hurt you, right?

But if someone is out using it around other people,

what one can feel positively about

or become sort of obsessed in the short term about

can be very counterproductive, right?

There can be a lot of risk to that.

So I think it anchors back to,

these are very powerful tools.

We’re coming to understand them much, much more.

And we’re coming to understand

that they have immense potential to be helpful to us.

But I think and hope that that only also increases

our respect for those modalities and what can come,

what negative can happen if we’re not respectful.

It’s gonna be very interesting

to see where all of this goes in the next few years,

not just in Oregon, but elsewhere.

It’s one way or another, it’s happening.

It seems to have a momentum that is not going to stop.

So very exciting area to be sure.

I agree.

I have a question about language.

In your book, you talk about how we need to be careful

about the use of language around trauma,

maybe problem solving and problem describing in general.

At one extreme, you hear that your brain and your body

hear every word you say,

and we have to be so careful with language.

And that actually frightened me for a number of years

because I would hear that and I thought, gosh,

if I just think that something is bad,

now it’s gonna hurt me worse,

which itself is part of that whole packing down of an issue.

Very hard to avoid thoughts.

Without distraction.

So that’s one extreme.

On the other hand, I can say,

I can tell somebody I love them with a tone of hatred.

I can tell somebody I hate them with a tone of love.

So how should we think about language in parsing trauma?

And in your book, you talk about,

you give some cautionary notes

about talking about depression, trauma, and PTSD

in terms that might diminish their real severity

in some cases.

And I was really struck by that.

So maybe just touch on,

how should we talk about these things in a way

that doesn’t diminish them for ourselves

or for other people?

And at the same time, honors the fact that

there’s a lot of trauma out there

and there’s a lot of depression out there

and we need to talk about it.


I think this is a very complicated

and in many ways, convoluted topic.

Like I think it’s wonderful that we have language,

but boy, language leads us astray often too.

You think about how people define words.

Like someone says a word,

what is it?

Does a person know what that word means?

What nuance are they taking from it?

We just have to be very careful

what we’re saying and what we’re communicating.

And I think this doesn’t mean,

because there’s a sort of phenomenon now

where people are trying to control language,

I think too much.

Like you can’t say anything

that someone else might find hurtful.

You have to refer to people in ways

they choose to be referred to,

even if those are ways that others don’t understand

or ways they themselves have decided

or ways that might be psychologically

or clinically unhelpful.

So I think the over control of language is not good.

But I think the specificity of language

of what are we trying to say?

How are we defining it?

Even the word trauma, right?

We’re talking about trauma.

So we want to define what that means, right?

It doesn’t just mean like,

oh, anything kind of negative, right?

Because then that dilutes it down to meaning nothing, right?

It also doesn’t just mean, you know,

injury in combat, right?

Like we have to talk about what that is.

So I think anchoring it to something

that rises to the magnitude of overwhelming

our coping skills and changing us,

like then at least I define it that way

and I can communicate that to you

and we can understand what we’re talking about, right?

I think that another aspect of language,

while again, we need this middle ground

and I don’t think that it is okay

for the over control of language to shut down expression,

but we also have to acknowledge, you know,

how we’re so much less distance from each other

through social media.

And I think social media can do very, very good things

as hopefully we’re doing now, right?

But it can also be used to harm people from a distance,


And how much hatefulness is there out there

that I think comes from anger and frustration in people,

again, back to trauma, right?

Where people just want to be angry

and it’s not really issues that they’re talking about,

but then there’s a target of that anger

and, you know, people feel beleaguered by that.

And the words that people use sometimes are so awful

that someone reading that,

like if you’re in the demographic that’s being targeted,


And you’re reading that, I mean,

how does a person not feel beset upon, vulnerable, right?

And then I think that also fuels, you know,

things like we just had this terrible shooting in Buffalo,


Like just hate motivated, right?

And I think that because that kind of language

becomes very real to people who may take it in,

it fuels their hate and then they do something to enact it,

which of course creates greater fear and vulnerability.

And I think there was some civility and decorum

that was in our world not that long ago, right?

I mean, you know, I’m in my early fifties,

I’m not that old, right?

But I remember a time when in political discourse,

people were civil to one another, right?

Now so much, I mean, it’s not all of it, right?

But there’s an acceptance of things

that are just bombastic, right?

It’s a circus sideshow sometimes

of people being just angry and aggressive.

And it’s not really linked to anything,

although it’s allegedly linked to something,

but then other people’s anger can attach to it.

And it’s not about what it’s about,

but it’s about aligning with the anger.

And I think that there is so much damage

that comes from that.

And I think, you know, should we have,

should it be okay that people sometimes are talking,

communicating, using language in ways

that would like get us suspended from middle school, right?

Ways I don’t want my eight-year-old to see.

I mean, is that really okay?

Or do we need to take a stand

for rational use of language?

I don’t want my use of language to be over-controlled

by someone who thinks they sort of understand better

than the rest of us, how to communicate with those.

Okay, I don’t want that.

What’s stereotypically a sort of idea of the left, say,

right, at least in our society.

But I also don’t want language,

it can be so angry and so aggressive

that it is perpetuating or spreading vulnerability

and that it facilitates trauma.

And I think we could set standards as a society

where we say, look, I don’t want anybody in power

who’s going to behave that way, right?

I don’t care if their whole agenda is like,

make Paul Conti’s life better.

I’m still not going to vote for you, right?

If you’re behaving towards others in a way

that’s denigrating, you’re behaving in a way

that I feel essentially ashamed of, right?

And I feel that a lot, right?

I see the politics, you know, I see things play out.

It’s not always political, of course, not always political,

but I see things play out and I think, oh my gosh,

I feel embarrassed.

Like we’re somehow okay with this.

Well, it doesn’t matter which side

of the political spectrum it’s coming to.

And I think that’s an indicator that what we’re doing

is really hurtful to us.

People become more angry.

They attach to the anger.

People feel more beleaguered.

There’s more divisions between us.

And it seems more and more like, well,

we can only really identify with people who are just like us

and like, what does that really mean?

I mean, the divisions that it creates between us

and that, you know, that promotes

so many negative things, right?

I mean, think about ways in which it promotes

white supremacy, right?

It’s just one example, right?

And we’ve seen that play out,

that this is really bad for us.

And we’ve got to look at that.

I mean, if we don’t look at that,

I don’t think as though something is going to happen,

like something is happening, right?

It’s happening now.

Yeah, and it really, to my mind,

it really seeps down into the soil

of everything that we’re talking about on all sides.


People are activated.

People are upset about one thing or the other, right?

No one is immune from upset,

regardless of political affiliation.

And everybody seems to be upset nowadays.

And as I was hearing you talk about this,

I feel a lot of resonance with what you said.

And I also am hoping you run for office.

Thank you.

I don’t think I have the gumption for that,

but thank you for that.

That would be wonderful.

Thank you.

I’d like to talk about a concept of taking care of oneself.

This comes up in the book.

This is something we talk a lot about on this podcast.

I mean, I think people have heard me blab endlessly

and I’ll probably go into the grave

telling people to get sunlight in their eyes when they can

and to try and get proper sleep

and to have a few tools for reducing their anxiety

in real time and on and on and on.

You know, we hear about this concept

of taking care of oneself.

And I think at a surface level,

it can sound a little bit light.

You know, oh, take care, take good care.

But to me, it’s a deep and powerful concept.

And I was very happy to see it in your book

and also to learn a lot of ideas

about what that really looks like.

Because whether or not somebody is in the early stages

of considering whether or not they have trauma

or is in the deep stages of working that through

or has made it through the tunnel some distance,

taking care of oneself is an ongoing process.

I’d love for you to just describe

what taking care of oneself means to you as a clinician.

And of course, the practices and things

that you encourage people to do,

but how should we think about taking care of oneself?

Because on one extreme,

you could imagine massages, retreats, vacations,

and chefs for hire that take care

of everything for ourselves.

And on the other extreme, you could say,

leaning into life in a way

that you’re paying attention to small things

while working very, very hard.

So it’s such a big concept,

but how do you think about taking care of oneself?

How should I take care of myself?

How should people take care of themselves?


I see here what I think is a very fascinating dichotomy,

that in some ways,

think about how complex our brains are,

how complex our psyches, our unconscious minds are.

There’s so much complexity there.

But on the other hand,

psychological concepts that are consistent with health

are often very simple,

by which I don’t mean light,

but simple, straightforward.

And I think self-care is absolutely one of them.

I mean, how much is talked about

how to take care of oneself

that just skips over the basics

that are necessary as a building block for all else?

So it doesn’t matter how many chefs or vacations

or whatever a person has,

if the basics of self-care aren’t squared away.

And it’s not a light concept to say,

like, look, are you sleeping enough?

Are you eating well?

Are you getting natural light?

Are you interacting with people

who are good to interact with?

Are you accepting negative interactions in your life?

Are you living in circumstances

that make you feel okay or not?

They’re very, very basic premises,

but so often we’re not looking at them at all.

We’re not looking at them at all

because we tend to skip over them.

And we tend to skip over them either

because again, in some automatic way

that sometimes is trauma-driven

or we’re not gonna look at that.

And often not taking care of ourselves

can have the punishment, distraction.

There’s so much that can come into that.

Or our sense of power is tied

to not taking care of ourselves.

I mean, I’ll give you an example is

I tend to, for whatever reason,

do reasonably well with very poor self-care, right?

And like, that was very adaptive

when I was into medical training, right?

And I’m like, okay, I can eat a lot today.

I can not eat, right?

I can sleep two hours.

I can sleep eight, right?

I mean, overall, that’s not good.

And it hasn’t been good for me as I’ve aged,

but then I realized somebody,

I’m doing all these things to make myself healthier,

but like, what, I ignore that, right?

And why am I ignoring it?

That was a key question.

Why am I ignoring it?

Because somewhere inside of me as it was,

and still to some extent is,

this idea that my ability to be really functional, right?

To generate success in the world around me

is tied to my ability to do that, right?

That, oh, but if I stop doing that

and now I’m like, I’m eating and sleeping regularly,

then I’m gonna lose some edge.

And so, and even I think about this all the time,

but I realized, hey, I’m also,

I’m not doing it inside, you know?

And I think it’s really grounding to the basics

that really help us of like,

what are the basics of what I’m doing

and not doing in my life?

Diet, exercise, sleep, people, circumstances,

leisure activities, I mean, sunlight.

I mean, I think immensely important

and dramatically undervalued.

I wanna thank you for that.

And I wanna thank you for today’s discussion.

I found it to be incredibly informative

and I know our listeners will also.

I also wanna thank you for the work you do.

I mean, you obviously run an incredibly

robust clinical practice that I’m aware

that you’re constantly trying to improve,

even though it’s operating at the highest levels already.

And I really, the reason why you’re here today

is because I’ve done a wide and deep search

for people in these areas.

And there are so few who have the background

in medical training and physiology

in the psychoanalytic and psychiatric realm

and also have a grounding toward the future,

you know, of what’s coming

and who can encapsulate so many different orientations

and bring them together into a coherent piece.

So I really thank you.

Yeah, and for your book, which is incredible.

I will go on record saying,

I think this is the definitive book on trauma.

And I really encourage people to read it

and will continue to encourage people to read it.

It’s so many valuable takeaways and insights and tools there.

So on behalf of the listeners and myself,

thank you so much for joining us today.

You’re very welcome.

And I take that to heart

and I’m very appreciative of being here.

So you’re very welcome and thank you as well.

Thank you.

Thank you for joining me for my discussion

with Dr. Paul Conte.

I also highly recommend that you explore his new book,

which is trauma, the invisible epidemic,

how trauma works and how we can heal from it.

It’s an exceptional resource,

both for those that have trauma

and those that don’t have trauma

or those that suspect they might have trauma.

Again, it’s a deep dive into what trauma is

and offers many simple tools that anyone can apply

with a therapist or not in order to heal from trauma.

And if you’d like to learn more about Dr. Conte

and the work he does directly with patients,

please check out his website,

We’ve also provided a link to both the book

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