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

Hey everyone. Welcome to the Drive Podcast. I'm your host Peter Attia. This podcast, my website and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, full stop, and we've assembled a great team of analysts to make this happen. If you enjoy this podcast, we've created a membership program that brings you far more in depth content. If you want to take your knowledge of this space to the next level, at the end of this episode I'll explain what those benefits are. Or if you want to learn more now, head over to peterattiamd.com subscribe now. Without further delay, here's today's episode. I guess this week is Dr. Paul Conti. This is a name that may sound familiar to some of you as Paul was one of our initial guests back in September 2018. I believe it was episode number 15. Paul is a practicing psychiatrist and recent author of Trauma the Invisible How Trauma Works and How We Can Heal From It, a book that brings his valuable insights about how we can collectively heal from trauma's effects to a larger audience. Paul's a graduate of Stanford University Med School, which is where we met. He completed his psychiatry training at Stanford and Harvard, where he was appointed Chief Resident. He then served on the medical faculty before moving to Portland and founding a clinic. This episode and my conversation with Paul is focused primarily around trauma, and in that we discuss a number of things. We talk about Paul's upbringing and his experience and how that got him interested in studying medicine and ultimately psychiatry and trauma. Specifically, we look at the impact of trauma on the brain patterns around trauma, and how often people don't recognize the implications of trauma in their life. We talk about the lack of biomarkers in psychiatry and psychology, the misguidance around trauma in the mental health system, how we kind of treat trauma as a symptom as opposed to going after the problem, and the importance of low lowering the barrier around trauma so that people can begin to receive help. From there, we look at the shame that comes with trauma, how shame is often the thing that prevents people from getting help, and how we can start to change the stigma around that shame that comes with past trauma. We end the discussion with a conversation around psilocybin and MDMA and their potential in this space. So without further delay, please enjoy my conversation with my good friend Paul Conti. Paul, amazing to be back here in person with you.

Thank you.

It's been way too long and the only thing I miss well, not the only thing, but one of the things I miss the most about going to New York frequently was that we got to see each other constantly. And now that we don't really travel that much, it's mostly phone calls.

But we got to spend so much time together, and I do miss that too. And it's just really wonderful to see you. I so appreciate you having me here and spending time with you and family. It's wonderful.

I'm excited to talk about your book, of course, but I think even though a lot of people have heard you on the podcast before, because we sat down probably three years ago, I'd probably take the assumption here that a lot of people are also hearing about you here for the first time. So let's tell people a little bit about who you are. What's your day job? What is it you do?

Sure, I'm trained as a psychiatrist, and a big part of my day job is being being a clinical psychiatrist. I also do some consulting work along the lines of understanding brain function and how brain function can impact us in personal or professional settings. But by and large, my work is really grounded in the clinical and I do have a clinic about 15 really great people I work side by side with in trying to meet the needs of people who bring us whatever mental health question there may be, which sometimes is clinical care and sometimes is just trying to understand themselves and the world around them better.

When is it in your journey of medical school and prior that you sort of had this inkling that you were interested in mental health?

I think around the time in the clinical rotation part of medical school, probably into the last year, when I realized that you could really be a doctor and understand medical things and how they impact people and really kind of be grounded in that aspect of practicing medicine, but also trying to understand people's experiences of life. Like what do people think and feel as they're going through their day? And that you could combine these two things and then be grounded to all the things one learns about life, just going through it and really help people in that way. And that just had such tremendous appeal as a sort of widely encompassing way of approaching trying to be of help.

Now, you, of course, didn't come to medical school in a typical way. You were not a pre med. You had been out and working for four years or so before medical school, if not more so. What were you doing, first of all, before you made this decision to go to medical school?

I worked for a consulting firm in New York and really enjoyed a lot of aspects of the work, the business, and the financial aspects of it. But there was just something I kind of wanted more. I wanted to know more and learn more and be more directly involved with people. And it was kind of a nebulous sort of theoretical set of thoughts, but it led to medical school to try and learn more and explore what might that be able to bring.

We've spoken about this, obviously, before you write about it in the book. There are a handful of events that occurred during your upbringing, your adolescence, that I think ultimately shaped how you now think about this thing called trauma. You want to talk about some of those things?

Sure. I had a really interesting course of life in the sense that in kind of the first half of my life, there weren't major traumas. So I was fortunate to have a stable family system around me and to develop a pretty stable sense of self, which is much easier to do if there aren't big traumas. And then in the second half of my life, there started to be some very major traumas. And to experience the traumas after having developed an orientation to myself and to the world that had been free of them was very, very striking. I think it put me in a place to see, even though I didn't completely understand them, but what was going on in me and what was changing in me and what were the impacts of the trauma on me in a way that was distressing and surprising. And I think that's also part of what led me towards mental health, where seeing, wow, these things are happening in me. And then there's a set of thoughts that come from that of, like, well, what. What happens if you experience these traumas and you don't have the good fortune to have a stable family system around you and have developed a strong sense of self? Because my sense of self was really thrown off by the traumas that happened, even though I had kind of gotten through those formative stages without that.

How old were you when your brother committed suicide?

So I would have been 24. 24 at the time that he committed suicide.

And at the risk of asking an obvious, or maybe not so obvious question, how shocked were you at that time? Because you hear these tragedies of someone commits suicide, and everybody around says, well, it was just a matter of time. This almost seemed inevitable. And then you hear these other stories where everybody around is in such disbelief, so they're really coping with not just the loss, but the feeling blindsided and guilty, and how did we not see this? And so where on that spectrum were you, and I guess by extension, your.

Family in the shock and disbelief side of the spectrum, which I think, like a lot of families that go through this, if one stood from the outside and looked at the development of events and what was really going on and what was changing in my brother, he had had a huge trauma a few years before where he had a very significant medical issue that had come out of the blue and was life threatening and really shook his sense of self. And he was very different after that in way that I could see in some sense, but not fully understand. So I think from the outside, one probably could have seen that there were these changes in him that would have meant it was not necessarily that shocking. But from the inside, we often don't see that, or we have our mechanisms of denial or of rationalization that tell us no things are pretty okay when really they weren't. And then the shock of it happening and then of realizing, oh, what could I have seen? Would I have seen? It contributes to a lot of the guilt and the shame that people feel. It's a bad combination, right? An immense amount of shock. And then immediately thereafter, a sense of guilt and responsibility. And also a sense that if there haven't been big traumas that, oh, like they don't happen, that's not something that happens to me or happens to us. And I think we can get into that mindset because it sort of psychologically protects us a little bit, but it can make the shock of a trauma like that, in a sense, all the more difficult because we start to feel cursed or unworthy or there's some mark of stigma that I think is just very, very frightening.

How did your other brother, your parents, cope with this, and how did you talk about it with them or what was discussed? And how did you all move on in the immediate aftermath of that?

I think my other brother and I were sort of built in somewhat the same way of kind of continuing to persevere and trying to find something new that can make life feel better, which often means working toward achievements, applying ourselves, which can be quite a good defense against trauma. I think in my parents, it was a little different. My father's a more sort of outgoing, gregarious person and was able to fall into a social network that was really supportive of him. Whereas my mother, who has since passed away, was more of a private person, less socially connected, and I think ultimately suffered from a lot of depression without her or us really understanding it. And I think that's part of what pushes so strongly towards my interest in trauma, is the realization of all the things we didn't understand or understood enough to. To know weren't good, but didn't have the words or the understanding to really talk about it and to talk about, like, what had happened and what it meant and the changes to all of us that we don't have a ready lexicon or a ready environment to be able to talk about things. And then people at times sort of retreat into themselves and then the trauma stays very, very immediate, even though that immediacy can play out over years and years. So I think we were very ill equipped. Like, I think most people, you know, we were just. We were ill equipped to handle a massive trauma and its impact upon all of us individually, let alone the greater complexity of all of us as a family.

Is it more common that in a situation like that, where a child commits suicide and the parents and siblings are left picking up the pieces, that very little is spoken explicitly? I mean, I think about the stories in my life of people I grew up with who. For whom suicide was a. Was an issue. So, I mean, had a girlfriend in college whose mom committed suicide, had a very close friend in high school whose dad committed suicide, had another girlfriend in high school whose dad committed suicide. And one of these had a very tragic outcome. The one there was a friend whose dad committed suicide. He later committed suicide. And that was an example of where I thought to myself, and it's something I felt very guilty about because I was in college and my mom called me to tell me he wasn't doing well. And it was in April and it was during finals. And she said, you know, and his dad had committed suicide two years earlier. And she said, look, he's really. He just doesn't seem like he's doing well. I said, well, you know, like. And I did. To this day, I just feel so ashamed over this. You know, I said, I'm going to be home in like, three weeks. I'll connect with him then. But at that moment in my life, nothing seemed more important than graduating first in my class. And anything that was going to stand in the way of that was. I couldn't go home for a weekend at my mom's request. And of course, by the time I got home, it was too late. He was dead. And I just wondered. It's so obvious. And yet I did nothing. What was talked about, what else was being done? So not to dwell on this too much, but I'm just curious how much you remember. In the months after your brother's death, was there a time where you sat around the kitchen table and said, Boy, it would really be great if we had a therapist here that could help us process what's going on. Or after the funeral, was it sort of like, nope, we're all kind of going to do our own mechanism of coping.

I mean, there was some discussion about it, and I think partly because maybe the generation I'm in, I mean, I hadn't been to medical school yet, so I had no knowledge of anything. But I'm maybe a little more inclined to want to talk about things. Like, I could tell, like, we all seem not to be doing well, but I didn't know the words to put to it. I mean, we don't, in a sense, give ourselves permission to have words of immensity, of impact, of, oh, my whole existence feels different. Like, we don't quite know or feel a sense of permission to say those things. And then often the reflexive nature of shame causes us to go inside. And I think that's a primary point that I wish to make about trauma, is that there is a reflexive shame that comes of being traumatized. The same shame we see if someone is assaulted and then presents talking about the assault through the lens of their shame, that it happened. These powerful stories that reinforce the reflexive nature of a sense of shame that drives us inward. So we don't have the words for it, and we feel very, very bad about it. Even the trauma that you felt as a result of not going home, like you say, well, it's so obvious, but it's obvious only in retrospect. At the time, it was not obvious because those words of desperation and of immensity were not being used. And we sit within a social context around us that in a sense normalizes not really talking about it in those big words or the words of, like, everything has changed, and I don't know what to do about that or what that means. And then we kind of move forward as best we can, but we're sort of limping forward without really talking about the things that matter. Which really starts with how differently we feel about ourselves. That I think we all felt a sense of shame and a sense of responsibility of what? What should I have seen? What should I have done? And he was living at home at the time. So for my parents, their thought of how they could have, would have, should have seen something, known something, that sense of shame drives everyone inside. And now we're trying to communicate and we don't have the words anyway, but we're muffled just trying to communicate while being sort of grogged or all of it. And we don't know. I don't know the words to say, and I'm driven inside, too. And then I think the things that we do often fail to give us what we need. And then you do see that cascade of trauma where one suicide follows upon the initial suicide, or the people around the person feel so guilty and ashamed that their lives head in different directions. I think my mother became depressed and more isolative, and it really changed the course of her subsequent life in a way that I think was very negative. Without any of us really knowing, how do we understand this and what do we do about it? And I think that's among the biggest aspects I'm fighting against of saying, look, we need to be able to talk about these things, like what's more important and what's more worth the time and effort to put the right words of understanding to than what happens inside of us after trauma.

You were living in New York, obviously, at the time. I'm guessing this was probably a very significant factor in your decision to take an orthogonal turn in your career towards medicine. But it's interesting that it turned you to medicine, but not necessarily to psychiatry immediately. It would take a few years within medical school to realize that psychiatry became the vehicle through which you wanted to help someone. I mean, everybody goes to medicine for the same reason. Generally speaking, everybody has some desire to help in one way or another. And then, of course, the purpose of medical school is to figure out the avenue in which you want to do that. What other thoughts did you have as you went to medicine, as it pertained to your brother? Or were there other factors that shaped that as well?

I see in retrospect, in myself what I often have seen in my clinical work over these past 20 years, which is there's a sort of bifurcation often after big trauma. And I had wanted other things in my life before my brother's death. I wasn't completely happy with my career, and I thought, well, maybe I want more education. And I had a lot of thoughts about that. And the idea of doing those things was really based on some sense of faith and confidence in myself that, like, hey, I could go do that. I could apply myself. I could learn new things. I could take a different path and figure it out. But after Jonathan's death, there was a bifurcation where I start to feel very differently about myself, to feel incompetent, to feel incapable. I mean, how could I even hope to take care of myself if I couldn't be a brother to my own brother and my Thoughts about myself changed in this way that, that I write about in the book and I think about and talk about a lot, which was sort of forgetting that I had a sense of confidence in myself and I was going in a negative direction of becoming less healthy and drinking too much and just wallowing in my own unhappiness through a sense of guilt and shame over what had happened. And it really came to a point of realizing this is not going well, and I. I'm sort of forgetting who I've always thought I was. And I got a little bit of therapy, which was a very kind of wild thing to do. Like, you know, no one went to therapy. And there was a sense of stigma even around needing mental health help after my brother's suicide. But even in that little bit of therapy, it helped me ground again to like, no, I don't actually feel differently about myself. And if anything, then I felt more of a drive, like, I want to go do this good thing. And yes, it was a drive to help people, but it was really based in a drive of self that, am I going to take care of myself in a way that says, if you're not happy and you want more of your life in the way that you see it, are you going to go do that? And that's where I think helping ourselves and helping others comes together. I mean, if I had no confidence in myself that I could guide my own life or be worth having in anyone else's life, how would I go off and do something to help other people? And I think that's often what we see after tragedy is in a very seductive and evil way. The consequences of trauma beckon us to limit our horizons, to see ourselves in a different and very negative way, which leads to bad things, it leads to depression, it leads to panic attacks, it leads to substance abuse. It just. It leads to not being who we want to be. And often juxtaposed to that is seeing the trauma through a lens that makes us redoubled in wanting to be who we want, who we can be. And our understanding of trauma, whether it gets the best of us and the guilt and shame wins the day and the changes to our memories of who we think we are, Is it going to be that or are we going to be lodged into life in a way that lets us move forward? And I was very fortunate to have gone the good path right instead of where it could have led me. And going to medical school was. Although, yes, I wanted to help people, you know, it was about me and my sense of confidence in myself that ultimately wasn't taken away by my brother's suicide. But man really could have been.

When you think back to your residency, you stayed at Stanford after med school for the first part of your residency before going to Harvard. You think back to those first couple of years, what stands out in terms of what you learned and how one teaches psychiatry? Because in some ways it strikes me as a more difficult discipline to teach than say, surgery. In many ways, if I think back to my residency, there's a knowledge base you have to glean and then there's a technical set of things you have to be able to do. And they're relatively easy to mirror. But at least from my vantage point, teaching somebody how to make a psychiatric diagnosis might be less challenging than teaching somebody how to talk to someone and elicit information that would allow you to make that diagnosis, or more importantly, communicate with a person in a way to help them. In other words, using words seems harder than using a needle and suture. So what is the process of education in a psychiatric residency program?

There's lots of learning of facts, of course, around neurobiology and around medicines and around different modalities of therapy. So I think in that way is probably similar to other fields of endeavor. But then there are the less tangible aspects that are the most important, like how do you establish rapport? Right. How do you really be present with someone? And I think that's where the training in the field, I think across the board often fails us. And I think part of that is sort of the world, the society we live in, in the world of modern medicine. I was very, very struck, and I can tell continue to be over these past 20 years how so much of what I learned, say, as a second year psychiatry resident, I think we should be teaching people in elementary school, and I really do mean that about just how we respond to the world around us. Even the idea that bullying comes from a sense of shame in the person doing the bullying, and then creates a sense of shame and inadequacy in the person on the the receiving end. And how does this all work in our brains? And how do logic and emotion clash in our brains? And emotion wins over logic, yet we're taught that we're logical creatures, things like that. I was in some sense actually quite incensed at a whole education process that doesn't prepare us to live life by telling us the basics of what goes on in our brains. So I was very struck by that and also struck that as I was learning it, it wasn't necessarily being directly Applied in the field as mental health has tried to kind of fit itself in with the rest of medicine. It wants to have very clear diagnostic paradigms. So this trend away from describing someone in a narrative, you say, well, how would you diagnose that person? Years ago, it would be in a narrative. You would talk about who that person was in at least a couple of paragraphs, and that's by and large gotten reduced to a number. And in trying to regiment itself in a way that I think is overly rigid and serves the field's interest and desire to integrate with the rest of medicine, we start losing the truth of really sitting with people and being present with people. And a lot of what I learned about how to be a psychiatrist was about boundaries with other people, which do in many cases make sense, but the boundaries were put forth in a way that was often about eliminating the realness of presence with someone. And I think that's the part that maybe is the intangible or the harder aspect of the field that I think doesn't really have to be that way. If we realize that we're going to help people through understanding, through really being with someone and trying to understand their experience, and of course, having it be about the other person, but being a real person with them, that I did find in my training process, but I didn't find in the field, which is largely moving towards these brief appointments and just giving people medicines instead of trying to understand what's going on with them. A lot of what I often describe as polishing the hood when it's very clear there's something going on in the engine. And while I learned a great deal, and I learned from some wonderful people who role modeled for me how to be with people you were trying to help, There was also a great deal of disappointment with a field that often in its training and its interaction with patients, ignored the crucial point of realness of the experience of the other person.

I want to think about the differences between these two programs you trained in, right, because you did half of your training at Stanford and half at Harvard, which are generally regarded as two of the finest psychiatry training programs in the country. But they have a very different method of training. So what did you find as you moved across the country for the second half of your training, and how did that impact the way you practice today? Because in some ways you have a luxury of having seen two very different approaches to psychiatry. A more sort of biologic and a more clinical, more of a sort of Freudian view versus a more, I don't know, how the way you would describe the one at Stanford. But it seems to me more of a neurobiology view. Both of which strike me as having huge benefits if they can be integrated. Was it received that way by you?

I think I didn't understand, certainly not at the beginning because Stanford is so neurobiology based. So the medical and neurobiological approach to psychiatry is just among the finest points of that program. And I was lucky to learn a lot of neurobiology, neurochemistry, function of medicines, aspects of the different parts of our brain and how they communicate amongst one another to generate our perception of reality and at times the problems that can afflict us. I learned a lot about that, but I think I didn't realize how little I was learning of the psychology of being a psychiatrist, of the unconscious motivations in us, of this rich history of understanding human beings that is so tremendously important to being able to help people. And it was only when I got to Harvard and Dr. Marianne Bataracco, to whom I'm eternally grateful, I think recognized in me, she was very impressed with the amount of biology knowledge I have. And I think that she was kind of horrified with the lack of psychology knowledge and then really helped me to get that knowledge once I was there from the people who could really teach it to me. And I ended up on the other side of that feeling like I had learned a lot of what I really needed to know. And then the way how do you put the rubber to the road of that Is by being a real person with the person that you're trying to help. Which I think is the way I approach the field. And the people that I work with, we approach the field the same way, but we're really the instrument through which all of that comes and hopefully helps somebody. So that maybe is in one's personality or you just kind of realize that, oh, when I am being sort of more rigid in a certain way, I am less helpful. And if I am less that way in a more existential therapy approach to realness with a person, then I can use all of what I've learned, the neurobiological and the psychological, to really make a difference to someone. And I think that I figured out through practice, right, and through learning what really helps someone. Just like I found my way to trauma, I didn't decide I'm going to be a trauma person, I'm going to write a trauma book. I saw it was undergirding a very, very high percentage of everything that I was trying to treat. Things like That I think we learn by trying to apply what we know. And I ended up being very fortunate to have had the brain biology knowledge and the psychological knowledge. Although it was a little bit distressing to realize when I got to Harvard how little I knew. And I probably wouldn't have known how little I knew unless I had had that experience that really exposed that.

When was the first edition of the Diagnostic and Statistical Manual published? I don't know where this fits in the evolution and history of psychiatry.

1948. Somewhere in the late 1940s, I think. 1948, but in that range.

And as you alluded to earlier, the DSM as it's abbreviated is really at least in part a way to catalog and create crisp diagnoses around psychiatric illness. Correct.

That's what it has evolved to. In the initial versions of the dsm, it was describing, in a sense, the phenomenology of like, what is this particular diagnosis like, what are the aspects of it, what's felt or experienced by the person and what's seen from the outside. And then there were sort of clusters of symptoms that would then lead one to think that that diagnosis fits, which acknowledges, since the unique aspects of human beings, that if we get too rigid about that, we start serving in a sense, the manual right. Instead of the person. And in many ways the DSM evolved as a way of allowing for research criteria to say, okay, we want to be calling a diagnosis sort of the same thing if we're going to communicate among clinicians and do research. But in my very strong opinion, that has come to a place that now is so overly rigid that now you have this very, very thick book that could give everyone multiple diagnoses because it's kind of designed to do that, and then come up with a number that justifies the 15 minute appointment in which the person has no hope of actually being understood in any way. Because you can't do that in 15 minutes.

And we're at the DSM 5 right now. Correct. We're in the fifth generation of this manual, which seems to get updated about every 15 or 20 years.

Yes, it's the fifth generation. There are technical revisions in between, but it's really evolved to something that I think is. Is so rigid that it in many ways works against the clinical care that we are trying to achieve. And again, I'm all for criteria and being able to have descriptive language and research criteria, but we've gotten to the point where it often gets called a bible, which I think is a very unfortunate word to use in many ways. It implies that there's something in that book that that actually tells you what mental health problems are and what they are not. And some of the criteria really make no sense. So, for example, someone who has vicarious trauma that they're experiencing, but not in an occupational framework, doesn't meet criteria for a PTSD diagnosis, which has come to me, like everything trauma. So if you have trauma that's real or legitimate, you have ptsd, and if not, you don't. Right. Like this clearly makes no sense, but the field often views it that way and then applies criteria that are not the be all and end all of the human experience and then becomes very, very rigid in a way that I think trivializes often what's going on with someone and trend towards that symbolism of capturing everything in a number as opposed to in a human experience. And I think we've gone so far away from the realness of human experience and how to sit with a person and be helpful that the field has in many, many ways led itself very, very far astray. And I think that the evolution of the DSM is both a driving cause of that and also a resultant symptom of that too.

Outside of Post traumatic stress disorder, PTSD, how often does the word trauma appear in the DSM? 5.

Well, it appears in other places, but it doesn't appear in a foundational way. Right. Because if the book is descriptive, then the book is looking to take an inventory of signs and symptoms. It's not looking at causality. And that is a problem because so much of the depression that I see, so much of the anxiety spectrum disorders, obsessive compulsive disorder, for example, abuse of substances and addiction, or alcoholism, is undergirded by trauma. And trauma changes that person's experience of life to a place of fear and vulnerability, and then that drives the subsequent problems. But if we're not looking at what's at the root of the things that we're describing, then we're just taking a descriptive inventory. And that's how we end up polishing the hood. Right. I can't tell you how many people I've seen with very severe substance disorders, disorders that haven't been helped by 3, 4, 5, 6 courses of treatment. And they're then often labeled as failing the treatment. And very often the treatment has never taken a trauma inventory. And it is trauma that is driving the substance use. It's trauma that's changed that person's internal dialogue towards something that's extremely negative, that tells them that they're not worthwhile. And they'll never get anywhere in life. And why try for a new job or a new relationship? Because nothing ever works out for you. And this wasn't that person's belief in themselves before trauma. It's undergirding everything, and then it's spinning off these symptoms. And then we take inventory of the symptoms as if they are the be all and end all. And then somehow we're surprised when the treatments don't work. So the fact that we're not looking to etiology, and I think that's a huge problem, and it fits with not actually paying attention to people that, you know, I would get handoffs that would describe a person in a number like, oh, who's the patient? I'm taking over. That's a 296.44 with a 309.81. They're like, oh, my goodness, right? We're talking about human beings here. But we've somehow reduced that to numbers that indicate a set of symptoms. And it's hard for me to see how one could argue the field hasn't been led astray if that's become the standard.

Let's define trauma as broadly as we can, because there's probably somebody listening to this right now who's thinking, okay, trauma could be an injury. And if they can extrapolate from that and say, well, psychological trauma. We talked about ptsd. I can see how a soldier coming back from Fallujah, having watched people getting blown up, both civilians and soldiers, I can see how that would be traumatic. Obviously, the story with your brother, yep, I can see how that's traumatic. But trauma includes much more than that. So how do you define, for somebody who's really hearing about this for the first time, what trauma means?

Trauma is anything that pushes our coping skills to and beyond their limits and then results in a set of feelings inside that could be acute terror, or it could be, for example, a chronic sense of denigration. But it creates these feelings inside that then change the functioning of our brain, the communication within our brain among the various parts, in a way that shifts the lens through which we see ourselves and the world around us. So it pushes our coping skills beyond the limits, and then it changes the ways that our brains function. And that's identifiable in modern science when we can see the changes in space aged neuroimaging that shows how the connectivity in the brain shifts, or even the fact that trauma changes the expression of genetically determined characteristics in us, because genes are either on or not on, and that changes as a result of trauma. And can be passed down to children even years after the trauma occurs. So someone can have the trauma occur, change the brain, and then have a child years later and the child is impacted by the trauma that occurred years before. So these are real changes inside of us, identifiable by modern science, that happen when our coping skills are pushed beyond, beyond the limits. And our view of trauma comes through this history of seeing trauma through the lens of combat. This is sort of the most obvious way to see it. Like that person went off to war and they experienced terrible things in war and they came back and it's so clear that they are different, right? So that's how we look to acute trauma, because it's the most obvious. And as you said, if, okay, there's a suicide and gosh, the family member members are traumatized and we can see that. But what we pay less attention to and less heed to are two different factors. One, the variables inside of us that determine what pushes our coping skills over the limits differ. It differs by genetic characteristics, it differs by early life experience. It differs by, for example, how finely tuned one's emotional compass is. It differs by the chronicity of trauma. So the sort of multiple hit hypothesis which we, we've seen, that if there are multiple traumas, it might be, oh, it's the fifth trauma that now pushes that person into a post trauma syndrome where the brain is different. Even though the fifth trauma might seem less traumatic than the first four, but the weight of the first four are there. So we tend then to paint with this broad brush that ignores the richness of human diversity and how we are impacted differently by different things. And then it also ignores the that not all trauma is acute, that there are traumas that are chronic. So you think of the trauma of neglect. Neglect of a child is not defined by an acute incident. It's defined by the impact upon that child of the neglect over time. The same thing with the aspect, for example, of systemic racism of a person who gets messages over time that they're less than, that they look different, they dress different, they worship different, whatever is going on in them is less than and that's inculcated into the person over time. And that can have exactly the same effects on the brain. And the same is true with vicarious trauma. I mean, we are fortunate, of course, as a species that we can be empathic with one another. We can experience the emotions of another person in a way that's connected as if they're our own. But the other side of that coin is we can be traumatized by what happens to other people. And sometimes that might be someone we're very close to, or it might be a person who develops such a strong interest because they're sort of horrified by things they see going on around the world and then are paying very, very close attention in a way that overwhelms that person's brain's ability to cope with that. For example, a person who was so deeply impacted by the crisis in Syria that then develops post trauma symptoms. And that person never left their home in the United States, but was so appalled and so distraught by what was going on and didn't know to divert their attention, There was too much attention to something coming from a good place in their heart. But that ultimately leaves that person manifesting the same post trauma signs and symptoms as people who suffer from an acute assault. And whether the DSM likes that or not, it is true. It's true. And it's identifiable in human experience. So the truth of human experience reflects the diversity of how we can be traumatized in acute, chronic, and vicarious ways. And that how traumatic things impact us and whether they push our coping skills over the limits is also unique to each human being. Which doesn't mean we don't feel follow patterns. And of course, the discipline of psychiatry, following patterns and identifying patterns is very, very important. But we also need to acknowledge that we are different and we can't understand what's going on inside of a person without paying attention to that actual person using that example.

It seems that at the risk of oversimplifying, there are at least two variables at play. There's the individual's susceptibility, and then there is the event or events which again, can be acute, chronic, or experienced by others that you witness.

Yeah, maybe circumstances. I would think of that as circumstances. Right, because event still in my mind implies something more acute as opposed to circumstances which could be an acute event or something chronic or vicarious.

So using that extreme example of a person who witnessing events in the news rises to the level of the definition of trauma, those events which are not being experienced by this individual over a prolonged period of time produce the state you describe, which is to say they are pushed beyond their manners of coping and they themselves begin to internalize shame and these feelings we're talking about. So does the DSM look at that and say that's not trauma, or it says there's something wrong with that person because they shouldn't be feeling that way based on that event?

I think it just excludes them because they just don't meet the criteria for what validates the trauma, which is interesting. So the book has to validate the trauma. And that does not really make sense. We should be looking at people and saying, do you present with the signs and symptoms of trauma that has pushed your coping skills over the limits? Is your mood chronically lower? Is your anxiety chronically higher? Are you having panic attacks you didn't have before? Is your sleep disturbed? Are you more hyper vigilant? Do you feel less safe in the world about maybe yourself or people that you love? Like these are clearly identifiable things. And if we're taking stock, what is your human experience and has something changed in you? Then the idea is we would honor that. And I wouldn't say, well, wait a second, that happened to you, but you were vicariously traumatized in the course of something occupational. So now, okay, so you get, I'm going to put the stamp of approval on you. Would that happen to you? But you were just so horrified by what was going on, say in Syria that you couldn't take your attention away from it and it woke you up in the middle of the night and you went on the computer for two more hours and now all of a sudden you really can't sleep well and, and you're fearful about your children in ways you weren't. Wait a second, that wasn't occupational. Now we're not. Now you don't get the stamp of approval. The idea is we have to anchor to the truth of human experience because it's not that extreme that people are traumatized by vicarious things. And I absolutely see this. I mean, I've written many more times than I can count on a prescription pad, like, I'm going to write you a prescription. And the prescription I'm writing is no more news because I see that that person's health, or maybe that person I've known for years, their health has reached, really deteriorated over a couple months of paying attention to something so intensely distressing. And we've had more than we can shake a stick at in recent years that you could pay attention to the point of like utter despair. And then who is that person? Like, is that person someone who's had three or four really acute traumas, but they don't have a post trauma syndrome, but boy, they're really a setup for it. So they start paying attention, attention to traumatic things they're seeing in the world around them and now they have a syndrome. We're not doing justice to that. If we're making a set of criteria that try and treat us like robots or machines instead of hey, these are human beings and we have to know what's come before in your life. Where were you at when you experienced an acute or chronic or vicarious trauma? And if we look at the manifestations of what's going on in a person and how do we help them understand it, then we can help people. I mean, part of the message of the book is this is not rocket science. There's a lot about this that's very simple and very grounded to common sense, which is pay attention to what's going on in people and help them understand it. And if we have an entire paradigm of helping that's around symptom inventory and putting a label or not putting a label and then schlepping some medicines and at someone without really trying to understand, then we often, even the first step we take down helping pathways is misguided. And then is it really a surprise that the mental health treatment system is not serving well the majority of people that it is supposed to serve? And I think it's very clearly true. I don't think this is an overly strong or exaggerated statement that accessing mental health help often leaves someone feeling worse. And I'm not trying to be over critical of the people working in the system. There's so many good people that are trying to help other people, but the system often doesn't let them do it. I mean you have panels of more patients than you can count in 15 minute appointments. How are you supposed to understand and help someone? So I think the entire system is misguided towards this. How little money can we spend in the short term? How can we get human beings out of the equation? For because human beings cost more money to deploy than medicines. We are misguiding ourselves in a way that's away from common sense. And we do often leave people worse than when we found them. A classic example being going to a hospital and trying to get help where maybe 15 or 20 years ago when a person I was taken care of might be in crisis, I would think if I don't send that person to an emergency that would be malpractice. They're in crisis, they need help. Now I have to stop. And the vast majority of times I do not do that because I worry or I know for sure if they show up at a hospital, they're going to wait 36 hours, 40 something hours before they see someone. They're going to be put in a place that's going to feel very shameful and very stigmatizing. There's A locked room. And people are watching that person in a way that makes them feel like they're being treated like they're crazy when they're in distress. And when they finally get help, there's some short term stabilization, give them a little medicine, they fall asleep, they wake up, they feel a little better because they slept, now send them home. And we're not serving people well with this short term view of how we're supposed to help them. I mean, there are not enough beds in emergency rooms, in mental health units. There's not enough time with practitioners. I mean, the fact that they the system is broken is to me as obvious as one plus one is two. I mean, I just see it in front of me day after day.

Where in the last 20 years did the matrix come together for you with respect to trauma? I mean, the first time you and I ever spoke about this was four years ago, 2017. And not surprisingly, at that time, I didn't really know what you were talking about. I only thought about it in the most literal sense, which is something that is so obviously physically harmful that that could be traumatic. But it was clear you had been thinking a lot about this because you had a lot to say on it. And you had already been sending patients to inpatient facilities, residential care, facilities that specialized in trauma care. So when did this occur for you? When did you start to integrate these other modalities? When was the first time you sent a patient to a residential program that specialized in trauma, such as the Bridge to Recovery or a place like that?

I would have been sending patients to residential facilities for trauma since very early on in my career. But not having the understanding like, you know, like when you do anything for a long time, like, you know, you internalize aspects of doing it that become reflexive and then it frees up parts of your brain to learn more. And as I got, I think just learn more and got more experience and more ability to spend more time with people and try and just always have a venue where I could try and understand that person led me to realize, like, wait, I'm doing the same things all the time. If you present to me with panic attacks, you present to me with obsessive compulsive disorder, you present to me with depression, you present to me with addiction. What I'm ultimately doing is the same thing, is I'm trying to help you understand why, because that's what's going to make the difference. And maybe along the way we can treat symptoms. Maybe I have you on a couple of antidepressants or even someone who has psychosis, something so dramatic that we're trying to decrease that with medicines. But ultimately how to really help that person is to try and understand what their experience is of it. Right. And their sense of vulnerability is of it. And I realized I'm doing this all the time, is trying to help people understand where the problems are coming from because that's how they get better. Which is the same as what I saw in myself was anger, frustration, resentment, underlying depression, like all of these problems were in me and a very negative and oppressive internal dialogue. And in my own psychotherapy of exploring this. We weren't trying to treat like what symptom is it spinning off now? But trying to understand like what's going on inside of you that you're doing this. And so I saw in my own, the process was to help me, my own psychotherapy and what I was doing with others, that it was all about the same thing, which were the roots of what ails us. And, and those roots are the seeds of trauma falling into a soil that lets those seeds grow. And trying to understand what is that soil inside of you? How is it unique to you? How does it follow patterns that impact all of us? What was that seed? How has it grown? I at some point realized, oh, that's what I do, that's what I'm doing. And I stopped thinking, oh, like how many depression cases do I have? Or how many? I, I didn't think about that. I said, oh, I kind of have all trauma cases. And that was such a revelation. And then in the practicality of starting to do my work more intentionally, that way I could see that it was more effective. It was very, very clear that it was more effective. And then I started working with really great like minded people and their knowledge and experience with what I was learning really came together in a way that this lens of trauma seem not like, oh, some esoteric discovery, but oh, I'm just rooted back to the obvious, rooted back to the obvious, which it's really some of the older literature in describing human behavior knew all the time, but just wasn't at the forefront of the discipline in terms of its education and training.

If you had to hazard a guess, what fraction of mental health providers, psychologists, psychiatrists, counselors, et cetera, have never referred one of their patients to a residential trauma facility, what would be your guess? It's an unknowable thing.

It's probably a pretty high percentage because trauma gets defined as does that person have ptsd? And people, they're not going to even say all the things that would lead them to be diagnosed. Right. Because they're ashamed of the symptoms.

When you go to one of these facilities, and I've been to two of them, the word PTSD almost never comes up. It's usually, you have this addiction, you have this maladaptive coping strategy. You're angry, you're depressed. Let's find out why. Let's find out what's underneath the surface. So given that the facilities themselves don't position themselves as PTSD treatment centers necessarily, although there are people there with ptsd, but it's interesting to me that practitioners aren't more aware of this tool. Let's take something like an eating disorder. You take care of many patients with eating disorders. What fraction of those patients would you say have an underlying trauma as a significant contributory factor in their illness?

Approach is 100%. Even if you look at trauma through that appropriately broad lens, because we're looking at what causes the outcome. So I'm not trying to look at what factors. Do I want to be part of it. I'm looking at. At the actual truth of what causes the outcome. So the chronic trauma of immensely high expectations of self, often placed upon self by self, but often that process being aided and abetted by external forces, which sometimes are the expectations of the people around that person or just the expectations of society of how you're supposed to look and how you're supposed to act and how you're supposed to present yourself to the world and what you're supposed to achieve can create immense senses of insecurity and of vulnerability. And people laboring under that for long periods of time can find an outlet for control. I mean, in many ways, that's often what the signs and symptoms of so many mental health issues are. It's an attempt to find control. And maybe somebody finds control by tapping five times when they think they have a negative thought, someone else finds control. Control by restricting what they eat, and they can control what goes into their bodies. And what are the roots of that? The roots of that are always trauma. I can't think of an eating disorder situation, A person suffering from an eating disorder who did not have trauma as a root of that eating disorder, with the trauma being discovered and talked about and addressed, at least to some degree during the treatment. And that's why the facilities understand this. I mean, it's interesting that facilities. No, because when you show up at a trauma facility, they want to understand and treat your trauma. They're not concerned. You have the magic card of entry of ptsd. But because medicine, how many times it gets said so often, but it's true, right? Of the doctors are treating the computer, the chart, the paperwork that so much of it is about, does that person have trauma or not have trauma? I got to determine if they have ptsd. It's so busying around with things that don't matter that are about establishing a diagnosis. So the insurance company will pay for the 15 minute appointment or will pay for the medicine that's going to treat the symptom but not the problem right there, then become a gating mechanism. And like PTSD is some magic gating mechanism that doesn't get talked about when you're actually treating trauma, because it actually makes no sense as a gating mechanism. And I think what you're pointing out is very, very powerful, that the world we live in says you have to have PTSD and meet these criteria or you don't have trauma. But what happens if you get to somebody who's treating trauma? They never talk about that. They talk about the reality and truth of what you've lived and what that has done to you in ways that are then counterproductive to your life. And that's the truth and the realness of it, as opposed to a false sense of surety that comes from all those guidelines and box checking that is really divorced from the human experience.

It seems to me that part of the problem, I mean, there's so many problems to the recognition of this. The first is medicine works in the sphere of biomarkers and objective measures of illness or disease. So we can look at a biomarker like a person's apob or LDL cholesterol or a hormone level, and it's subjective. We can understand what that implies, or we can look at a CT scan that shows an injury here or there. But psychiatry has none of these things. Psychiatry doing an MRI of a person's brain offers you no more insight into their plight or their suffering than rubbing a towel on their head and dumping some hot wax on it. Again, there are exceptions. Of course there are exceptions where certainly a nutritional deficiency, like a B12 deficiency or something that can show up in a biomarker can explain a psychiatric heals. But. But for the most part that's not the case. So that's. I call that kind of macro problem one. I think macro problem two is the heterogeneity of the soil that you describe. You could take 100 individuals and simultaneously expose them to the same traumatic event, but without knowing what their antecedent History is what else has this person experienced? So in other words, what else has been dropped in the soil? And without knowing the composition of each of their soils, you really have no IDEA how those 100 people are going to react to an identical stimulus. And that, of course, is very uncomfortable for medicine when, you know, it's uncomfortable for science. You think of Koch's postulates. We really love it when we can say, add this microbe, get this disease, subtract this microbe, subtract this disease. Medicine is so good at that type of thinking. And again, I'm not saying this to be critical of medicine or to be critical of psychiatry. It's just an observation of maybe this might explain to somebody who's listening to this, who thinks you're out to left field. This is a very hard problem to quantify because of these a. Again, the obvious, the lack of biomarkers, et cetera, the lack of diagnostic criteria, and the incredible heterogeneity of the individual and their history. And those are actually not the same thing.

Yes. And I think on the one hand, look, we need to acknowledge that complexity and also that lack of specificity. But on the other hand, there are aspects of that that I think simplify in ways that are very, very compelling. So in the book, I interview Stephanie von Gutenberg, who's an expert on understanding and prevention of child abuse, and Darren Richard, who's a professor at Stanford, who's done a lot of trauma work and trauma research around the impact of trauma on identifiable markers and what that means. So, for example, his work draws at times from the field of epigenetics, which shows that gene expression changes after trauma. And his testimony was instrumental in jurisprudence on an international level recognizing that, for example, rape as a tool of war is not a one event criminal act, which was how it was being viewed. Okay, that thing happened on that day in a way that circumscribes it. And the epigenetic research around trauma shows that not only is it not a one event limited to a day experience, but that it carries on throughout that person's life, it impacts the society in which that person lives, and it gets passed on to the next generation. So now we start having that kind of powerful science that can show that woman who was raped has a child three years later, and the genetics that are expressed in that child are impacted by the trauma that happened three years, say before conception. So we do have, in a sense, the scientific proof to hang our hats on these days. We do have that in a way that tells us right we kind of knew all this was true because we saw it obviously in front of us. Now we do have what science wants to have to hang our hats on. And even though, like, say, those hundred people have different soil and will be affected in different ways, we can understand how that may sort of disperse across those hundred people. Right? Like, what is the trauma? A certain number of people, a percentage of people, are likely to respond in certain ways. If it's a dramatic trauma, like if there's some dramatic acute trauma, it might not matter so much what the soil is. People are going to be. The majority are going to be very deeply affected, or there might be other kinds of trauma where you can only understand by really understanding that person. So we do fit patterns and we can understand how those patterns unfold, just like we can understand the aspects of basic science that we've learned now in a way that says, yes, this is very, very complicated. That's why it can't be deployed in some checkbox kind of manner. But we can understand it well enough to say, okay, it's actually not that complicated to try and understand, like, what has your experience been or what's going on inside of you if you present as depressed? Well, what's your history? And what are you saying to yourself inside? And has that shifted over time? We can understand that in a way that says, do I think that your brain is different because of trauma? It's not that hard to do that. And then to say, well, let's try and understand your trauma so we can help make it better. So there's an aspect of this that's also kind of simple, too, that we don't deploy because we're lost in the complexity of all those other things, all that box checking, and we don't know, we don't understand. And psychiatry wants to be like the rest of medicine. And then we get lost in the complexity. And that complexity very often prevents a person from being understood. Feeling understood. Feeling help. Getting any help at all.

Are there checklists that provide value? So, for example, the adverse childhood event. Is that what it's called? ACE. It's a series of questions, right? It's 10 questions, 20. How many questions is it?

I don't know. There are different versions that get utilized in different realms. And I'm not. I don't know what the standardized version is now.

Yeah, yeah, yeah. But it's in that ballpark. So sometimes these tests are really good at catching. They have a high positive predictive value, but they seem to have a low negative predictive value in Other words, there's lots of people who don't score highly on the adverse childhood event score, but nevertheless, there is significant trauma in their lives. But it might only account for one of the 10 checks. But again, for them, it was very instrumental in how their identity was formed. So is this something that can be automated, or is this something that can only be done by someone who has the ability to dig and really get deep into it? So let's take an example. Let's take a person who grew up in a family where they simply weren't paid attention to. They would check the box of neglect, but none of the other boxes would get checked. Now, let's say there were multiple kids in that family, five children neglected because the parents are working like crazy or for whatever reason. Those five kids could completely internalize that in different ways. Some of those kids could go on to become the most successful people in the world because at least externally, because of a drive that gets instilled in them to prove their worth, one of their siblings could easily go in the exact opposite direction and turn to a life of substance abuse and addiction.

We see this all the time.

Exactly. Let's explore that a little bit more because again, there's two things I want to explore there. One, something as innocuous as neglect can produce such vastly different phenotypes. And secondly, the heterogeneity of the soil problem, again, which is how is it that two siblings, and you and I have both seen scenarios like this. Two siblings in the exact same family exposed to the exact same stimulus or environmental factor, in this case neglect, can have such vastly different responses. And one of them society frowns upon and the other one actually society's pretty impressed with.

Right. And so the question is around the heterogeneity of it or how do we understand it?

Well, I think it's both. Right? It's how do we explain the heterogeneity? And two, how would both of those people even rise to the level of coming to the lens of trauma, given that? Again, I'm using this very specific example where on an ACE score, neither of them would rise to the level of concern.

Right? We are different. Even if we are siblings, the genes are different and their manifestation can be very different based upon aspects of early childhood experience that may have nothing to do with trauma. So I think where it leads us is inventories of signs and symptoms can be useful, but they're just one element of data. I mean, one aspect of it is accuracy of reporting. People will often under report because trauma creates Shame in us. I mean, I can't tell you the number of times, say, someone comes to care with me and they're checking, oh, they have depression and panic attacks and say there's some intake form. They don't check the trauma box. Okay. And maybe I meet with them and maybe there is like a purely biological depression. It comes out of the blue and I can't find trauma associated with it. Like, that happens. It's rare, but it happens more often than not when you start talking to the person. It's remarkable. Sometimes I've thought three sessions worth of trauma history that's intrinsic to all aspects of that person's life. And they check. No. On the trauma box. Well, because they didn't really think this was trauma, and they really think that was too long ago to be trauma. And like, that's not as bad as what other people have to deal with. So that can't be trauma. I mean, this happens all the time.

What you just described strikes me as the norm. Right. Isn't it that the majority of people who come into kind of a trauma diagnostic scenario with an astute provider, but it's the comparisons. Well, I mean, come on. What happened to me is not that bad. Look at what happened to so and so. That can't be trauma. And that was a long time ago.

All the time. Absolutely all the time. Because. And this is really a crux of the messaging of the book, because trauma changes the instrument that we use to understand our trauma, it's changing our brain. So you combine that with how much shame is evoked and how hard it can be to discuss that. Because if we're ashamed of something, we don't want to reveal it to somebody else. And we often don't know. Just because it's a professional, is that person going to feel okay about me or are they going to look at me differently because they see that shameful thing in me? We feel this. And absolutely I felt this after my brother's death. I'm going to go see this therapist. I don't even know this person. And what's she going to think of me? Like, you know, here I wasn't around enough. I only lived two hours away, and I wasn't home enough to see this. And, like, you know, I thought maybe she was going to say, shame on you for what happened. Like, I didn't know. And I think that is the norm, which is why, like, we can't replace humans. We kind of understand this, that we can't replace humans in our helping endeavors with, like, Something that's computerized, so. Or mechanized in some way. So, sure, we want to take inventories, and if we can, if it makes sense, take an inventory of trauma signs and systems. But realize that you have no idea what that data means until you sit with the person. Why should it be strange to say that human beings are a necessary part of this helping process? Because often I may look at all the data I have from someone, and a lot of times I have data even from other providers or other facilities. I have a lot of data, and I'm like, okay, it tells me something, but I really don't know anything really about that person until they sit in front of me. Because once they sit in front of me, I can anchor that data to something. And very often what I started seeing over getting more experience in the field was when you talk to more with a person about what's going on in them, it is indeed linked to trauma, whether they've checked that box or not. And it's all those barriers. It was too long ago, or they feel ashamed of it, that lead them not to recognize that the trauma is driving all of the problems. And I think that the last story in the book about the woman who is a true story, who 10 years later, is 10 years younger, and I got her permission before writing it, because I didn't. That's not a composite. Right. It's this. This person who just didn't understand, like, how her life changed the story. So she had had a tragedy in her life and it was years before. And just standing from the outside and hearing this story, there was such a disjunction of how she felt about herself and felt about her life and was living her life that changed after the trauma in a way that. That was so stark.

This is the woman whose daughter died. Yes.

Who without realizing it, was living this life that was so changed. And her thoughts about herself were through such an unfair lens, who really had no, despite being intelligent and personable and all these wonderful qualities, couldn't see it. And that's not the exception of that's the norm. And those rationalizations inside of herself that, no, it was too long ago, or even feeling so badly about it that being unable to let it to the surface enough to see what it was doing had driven all of this change in her. So despite attesting to not having trauma, it was 100%.

How did she come into your care.

To treat some of the symptoms that had spun off, which is often the case, like, oh, this person is depressed, or there's just so many things. I'm like, okay, that's. That's just the card of entry. Like, maybe that I will find there a pure biological depression. But I have ceased to believe that that is what I will find because 20 years of doing this intensively has taught me differently. So then in this case, the person comes in and I see whatever the presenting. I don't remember right, because, like, that's not where the money was at, so to speak. Where the money was at was in trauma. Right. And is this that leaf at the end of the tree that caught the person's attention? I want that leaf to be a little healthier, a little bit better. That then brings her in where we look at what's going on in the roots that's affecting all of the leaves. And it then gives us a chance of actually getting at it and developing an understanding of trauma and of reflexive shame and what that does to us. And what a change in internal dialogue from feeling a sense of pride in oneself as someone who works hard and does good things for other people and in the world around her, to someone who. Who couldn't see her own worth anymore. And you want to see an absolute disjunction of oneself from before and after that will do it and by understanding, could get better. Does it take away the grief? No. In fact, it let her begin to process the grief. Because if we're blaming ourselves, we can't grieve. That's why it can be 50 years later and be just as immediate as when it happened. Because. Because if the grief gets walled off under this layer of shame, like an abscess medically would be in the body, then it can spin off symptoms for years and years and years without anything ever getting any better. And in fact, with things getting worse, because the trauma then brings new trauma, it brings the shame of losing jobs and losing family and all the ways in which feeling bad about ourselves makes us feel worse about ourselves. So it's a great example, but it's not, oh, that's one in a million. It's just a great example of something that I see all the time where she's like, let's get to the truth of what's going on in the person, help them understand it, and things get better. And it's not that hard and complicated, but it requires an approach that actually wants to understand what's going on.

Actually, I've always found the analogy of the abscess to be quite helpful, especially for folks who understand what an abscess is, how it's formed and what the implications are of it. So for maybe folks who aren't familiar, an abscess is a walled off infection. So a great example of how one might get an abscess is if they had a ruptured appendicitis. And you know, a ruptured appendicitis carries with it a very high mortality. But there are some ways to survive it without antibiotics, without anything. And this was even known hundreds of years ago when people were making long haul journeys across the ocean. If you had a ruptured appendix in the middle of the Atlantic Ocean, when you're halfway between Spain and the Americas, kind of sol. But what they realized was if you put the person on their right side down, tilted slightly, head up, all of the pus that was coming out of that ruptured appendix would at least wall off in the lower part of the right abdomen as opposed to spread throughout the entire abdomen. And there was at least you'd increase the odds that it would form this fibrous capsule around it that would wall off. So you'd have all the pus and all the nastiness inside there. But it would, it was sort of walled off. And if you could get this right, that person might, just might survive. Now, they weren't going to be perfectly healthy, but they'd survive. Now today we still see people that show up with abscesses from a ruptured diverticulum or something like that, and they're not well, they're not dead though, but they're just not well. Well, the first thing that has to happen is they have to come into the medical system for treatment, which I guess the analog would be here. They have to at least present for help in some way. The second thing is they have to be willing to get help. They have to acknowledge, I have an abscess. Now, it's a lot easier with an abscess because we have a CT scan that is stark. I mean, an abscess is an unmistakable thing. You don't even need to be a radiologist or even a medical student to spot the abscess on a CT scan. It's the easiest thing to see. Literally. There's nothing easier to see on a CT scan than an abscess. But nevertheless, there's got to be some component of convincing the person that you have this abscess. But what's interesting is the treatment. You often get a little worse before you get better, because when you open that abscess and you release all of the bacteria, even though you're doing it In a manner to clean it up, the patient will initially have an inflammatory response to that that is probably worse than the condition that brought them in. Now, of course, you have the luxury of doing this in the hospital. You're giving them antibiotics, you're giving them IV fluids, You're monitoring them. So this is rarely a fatal event, but it's nevertheless uncomfortable. And in many ways, that just strikes me as a great analogy for what has to happen here. Except it's harder in the case of trauma because, one, they might be less likely to come in and seek help. Two, you have a really big hurdle to actually convincing the person that you have this abscess. And three, the treatment is much harder in many ways. The treatment of the abscess is really quite simple. You're going to be under anesthesia for the next couple of hours, and we're going to do all this stuff, and we're going to give you a bunch of antibiotics. Well, it's a lot harder to do what you did with that woman than what I would have done with that patient.

Yeah. And I think as I'm listening to you, what it makes me want to focus on is the really big hurdle, because I think the abscess. It's a remarkably good analogy.

It saved you. Your response to the trauma saved your life. Right.

We're built to recoil and protect ourselves from dangerous things, which is why, if you think about trauma leading to avoidance and hypervigilance, and people become more afraid of the world and less likely to engage and less likely to take chances, even if it's like, the chance of a job that seems better or the chance of dating someone who seems like they could be a great partner, taking chances in good ways, that person becomes much less likely to do that. And if you think about how these systems grew in us, that trauma raises a lot of negative emotion in us. And then we recoil to protect ourselves. And it may be that even a depressed mood or a lot of panic attacks and disturbed sleep, this may all go hand in hand with hypervigilance and avoidance. To say, look, that is better than death. And when these systems grew in us, where a lot of the trauma that happened did tell you to stay close to home. Human development. And we're in small groups. And if you eat something that makes you sick, never, never, never eat that again. Or if you go over that hill and someone from another tribe. Tribe attacks you, like, don't go there again. Just stay closer to home. They're there for a reason. They're part of the evolution of human beings psychologically over time in order to stay alive. But then in the modern world, those things don't always make sense anymore. And that walled off, say, psychological abscess that is indeed better than death is spinning off symptom after symptom. It's making that tendency towards a little too much alcohol soothing that that person does a couple times a year. Well, now they want to do it a little more because there's a desperation of them to not feel so terrified or have panic attacks when they're falling asleep and now they're drinking three, four, five, six, seven days a week. Or that tendency towards avoidance is now they can't get out of bed or leave the house. These are things I see all the time. And often what brings a person to care is a symptom. Just like the person with the abscess might come to care because they don't.

Know they have an abscess. Exactly. They just don't feel well.

So the parallel is so strong there. And I think the difference is in the hurdle that even though I might say, okay, wait, I'm going to feel a little worse before I feel better. But like, oh, I see that bright thing on the CT scan and you're telling me you're going to go in and take it out and I'm going to feel a lot better, not just this thing that brought me in, but 50 more things I didn't know about. I'm much more likely to say yes to that. And the problem, I think is in how high the hurdle is for trauma. And I guess actually, I think the problem is twofold. It actually is in. It's not as easy to recognize as the abscess. But I think that it should be that our mental health methods of helping should look for this.

In looking for abscesses, we have 256 bit CT scanners that can produce a resolution of one by one by one millimeter. And the analog of what you have in psychiatry to do this is pre CT scan era, when you have to just palpate somebody's belly and surmise that they have an abscess. There's a huge. I mean, I don't want to use the word technology to imply that you will need technology to do this, but it is effectively the difference between a catapult and a cannon.

But I think maybe the beautiful answer to this is in this example we're setting forth, psychiatry is choosing to use the let's palpate the abdomen instead of the CT scan.

I completely agree. Yes, yes, yes.

Because the human brain has more sophistication than even that finest CT scan, right?

That's right.

So if we apply the trained human, human brain to say, look, I want to try and understand what's actually going on in you instead of saying, oh, oh, you're depressed, you checked all the depression boxes. Let me give you an antidepressant and I'll see you again in two months. And we won't make eye contact. I mean, like, that's not helping. That's not understanding. But if we apply the human brain, like we apply the CT scanner, then we will identify way more trauma and say, look, how many times I tell a person, here's the great news is you do not not have five problems because people will present saying, you can't help me. There's no way you're going to help me. Right? This has been going on in me for years and I have four different problems, right? How are you going to help me? Right. So here's the great news. Been going on for years because it's never been looked at. So it's not surprising it goes on for years. And you don't have four problems. You have one. You don't have depression and sleep disturbance and panic attacks and alcohol abuse as entirely different problems. They're arising from trauma. And I may be. Why would I be saying that? Because we've had a couple of conversations where the person told me how none of those things were present before the trauma and all of those things are present after the trauma. And then that's not rocket science. So we could stop palpating the abdomen and bring in the equivalent of the CT scan or even better, right. The human brain. And then we can identify what's going on and we can also decrease the hurdle. Why is it so daunting to get help for trauma? Right? I mean, in many ways it is scary because the person often has been keeping it inside. And I hear this all the time too, like, I can't talk about that because then they realize, and often they knew all along. Not always, but often they knew all along that that's what was going on. Because they get told, the whole world inside of me is different now, but look at what it's doing to me, and I'm not even talking about it. They don't realize, look at what it's doing to you because you're not talking about it. But when you can get someone to understand that, and often that comes already, that's right there waiting, because you're talking at least enough about it. That the person has disclosed that there's been some trauma. They put words to something they maybe never put words before. And guess what? The world didn't end and I didn't lean across a table and say, what, like, get out of my office. Things that people are afraid of. Like, I was afraid after my breakfast brother's death. Already there's an people. This happens all the time. We say, I feel better now. I already feel better because literally after just 40 minutes, say, of talking about, like, yeah, you know, I really have felt different since that car accident or even since that thing happened to my friend's child. They know, but because of the shame and the idea of, what are you going to do with that? They don't know that there's helping resources. So we. We don't put it out there that there's helping resources. And people have way too many experiences of going to get help and then they come out with a prescription for an antidepressant from somebody who didn't really talk to them and they know that's not going to help, or they've already done it four times and it hasn't helped. So we create these barriers by, like, so many things in modern medicine, by stepping away from common sense. Like, let's use the right helping mechanism, let's use the equivalent of the CT scan to find the abscess, and let's make the barrier lower so the person doesn't have to feel that it's utterly terrifying to go through this helping process. Once people start doing it, even though it's difficult, people feel good about it. They feel good about it. Like you feel good about doing something that's hard for you. Working out is really hard, but you know you're getting healthier, so you don't mind going and doing it. And that's often how the experience is. It's not miserable. And it often surprises people that, like, the clinic that the whole group of us have together, it's not a miserable place to come. And people are often surprised by that, that this is supposed to be miserable, it's supposed to make them feel bad. And if you come to a place that's just reasonably nice and you meet people who are like, hey, I'm in the soup with you, too. I know things, I'm trained. That's why I can help you.

But I'm finding that in the short term, it can be quite distressing to go back and revisit these things. I think that's been more my experience than not, both personally and with others. That it really does feel a little bit like that abscess, where in the days after that surgery, in that case, the patient actually looks worse.

Yeah, absolutely. Absolutely, yes. But because you know why and you know that it's helping you, it's much more tolerable. This happens in my own therapy. I'll think, gosh, I've got to talk about something from the past that is now being triggered. Right. Like something happens in my presence and it links me to a trauma of the past that really shook my confidence and now my anxiety level is higher. And I know it's going to be hard to go in and talk about that. I know it. I know it's going to be painful, but I'm not afraid of it because I know that it's helping me. Just the way that people perceive pain differently in medical settings if they know why. I saw a study you probably have seen around gunshot wounds and people's pain being so different. If they see that there was some reason they're trying to help somebody, and now they know that even though this is terrifying, they're going to survive it and their level of pain goes down. So, yes, it's painful, but the perception of the pain is this pain that threatens me, menaces me with destruction, or is this pain that, although painful, is in the service of doing right by myself? And that's often what we'll anchor to. Look, I don't see a reason for you to have a dialogue running in your head where 500 times a day you tell yourself that you're worthless. Really? That doesn't seem fair or right to me. Not even sometimes you joke. I don't know. Have you been kidnapping buses of school children? I don't know about. Is this it? There's something to feel ashamed about here, but it's the person who did that thing to you. Maybe there's nothing to be ashamed about here because something just happened in life. And it's that change inside the person that gives us all the bravery to go and do difficult things, because we see that it's aligned with truth. And I think often people see psychotherapy as like, oh, we're trying to shift towards something that feels better. Like, that's not the purpose of it. The purpose is to shift towards something that's true. Oh, and by the way, that true thing feels better.

What do you think are the impediments to a person once they're presented with a plausible explanation for their symptoms? In the Roots of Trauma, what are the impediments to them doing the work that's necessary. Because again, here's the second huge difference from the abscess. The abscess. You get to basically put an IV in your arm, take some propofol and wake up and have it be over. When you're confronted with these events of your childhood, though seemingly completely disconnected from the problems you're having today as an adult, are probably causally linked and we need to go back and talk about them, and we need to go back and process them, and we need to go back and disconnect your shame from those things. There's a lot of resistance that's met there. I mean, last night over dinner, you and I were talking about common patients whom you get the feeling that they might not take treatment.

Yeah, I mean, I think the biggest problem. Because I said what are the problems? Right? And the biggest problem is presenting to a system that is not looking to throughput and minimal short term cost as the primary metric of success is that brings the frustration of not finding what's needed. And what's needed, of course, are skills that are learned through education and training, right? Their neurobiological knowledge and pharmacological knowledge and psychotherapeutic modality knowledge. But most importantly, it's presenting in a setting where there can be what's called a holding environment. The reason that we can do these things that are very, very frightening is because we establish rapport with someone who we feel and believe wants to help us, is capable of helping us, doesn't want to look down on us, and can help us hold the distress of it. And that's the commonality, like the psychotherapeutic modalities are so very, very different. But if you look at primary pred of success, it lies in the rapport. Because the rapport, the trust, the mutuality that's generated is what creates that thing that's called the holding environment. Which is like, I'm really, I'm scared of this and it's intimidating, but like I'm going to come here and this is a safe environment and you're a safe person and you want to help me and I don't feel bad when I'm sitting across from you. Which is why me and most of the people I work with, if not all, acknowledge our own trauma. I mean, we're not talking about it in a way that serves ourselves when we're supposed to be serving someone else. But I'm not pretending that I'm not a person for whom trauma isn't deeply ingrained in my life. And that sense of mutuality leads a person to feel the trust and to be able to tolerate the distress because they're not tolerating it alone. And when I pack up my trauma at the end of my psychotherapy sessions, I'm going to carry that until the next time. I'm going to go back back, in part because the person I go to for therapy makes me feel helped and understood. And I know that he's going to carry it with him and he wants to help me, and he feels a sense of respectful camaraderie in the work that we're doing. And then I can bear the distress of it. I can take it home with me, even if it causes me some symptoms thereafter and know that I'm going to come back next week and I'm going to make more progress. But our helping systems have to be set up to do that for people. People.

Let's assume those are in place. Okay, let's assume.

Big assumption though, right?

Big assumption, Big assumption. But let's assume that that is in place. Why is it that 10 people who have childhood trauma or early life trauma that is producing very maladaptive responses in their lives, either with respect to self, care, care of others, any of the other manifestations of trauma, what are the things that stand in the way of them accepting that information and moving forward?

So, first three answers are shame, shame, and more shame. Trauma makes a reflexive shame in us, and that's what tells us to make the abscess. What's interesting is in the appendix example, the abscess happens because a biological process happens, and now the appendix bursts. And then maybe the body can figure out a way, especially if the person's leaning on the right side, we can figure out a way so that walls off. But the difference here is the creation of that abscess occurs inside of us through our defense mechanisms that say, I've got to wall this off. I can't think about this, I can't talk about this. I didn't want to go to therapy after my brother's death because I was ashamed to go to therapy on top of the shame I felt about his death. So we do it to ourselves because that's what seems like the course of action that safest, and that's very, very powerful when we're promoting that process. And then because things aren't going well, we sort of wall off that abscess more and more and more because other shameful things happen. Like after my brother's death, when I wasn't functioning super well, and I didn't feel like I was taking good care of myself. I felt ashamed of that, too, which then makes it harder to get help. So shame, which is like the primary henchman of trauma, right, in my view, comes along with all. All these other accomplices. Like shame loves alcohol. Excess shame loves an internal dialogue that tells you that you're not worth anything. You're not going to get anywhere. There are all these things that shame loves that we then cultivate in ourselves and we apply to further walling off, further pushing that problem down. And that's why the best route is not just, okay, let's shift how we're handling the care. So if you go to see someone about whatever your symptom is, that person is actually thinking about you. But we do need, in my very strong belief, to change the sociological aspects of this, to look and say, like, look, many, many, many of us have really significant trauma that is, that has overwhelmed our coping skills, changes how we view about ourselves and the safety of the world around us. And it really behooves us to look at this, and there's no shame in this. I remember this was a bunch of years ago, but I was talking to a group of about 300 physicians from mixed backgrounds, mixed disciplines, and I said this. I said that I've had really significant trauma in my life, and psychiatric care and psychiatric medicines have really helped me. And I could see out in the audience, probably about a third or so is a rough estimate of people shocked that I had said something that was so shameful, as if the next thing that was going to happen is someone's going to fly through the air and tackle me and pull my medical license out of my pocket and put me someplace where people go who need those things. And I said, look, this is a problem because I can see, and I hadn't planned on this. I said, it's a problem because I see a lot of you really recoiling from this. And I'm saying something that I don't think takes away from my ability to be a competent physician or a competent person in the world. And I think, in fact, being able to say it is what helps me navigate the world. But if we recoil from, like, oh, you might need help, right? Or you might need medicines, like, what is going on inside of us? That means how likely are any of those doctors to get themselves help? And how likely are their patients to feel comfortable if they broach something traumatic, to hear something back that even if the person's not in mental health, right? But just say, wow, okay, look, we know that way more than 50% of complaints to general medical providers come from mental health conditions. I mean, the studies show a bottom of 50% and a ceiling that's significantly higher than that. So non mental health providers have to be aware and not respond in this way. And again, I'm not trying to be critical, but you see that response even in mental health. Some of those people who were coiled were almost certainly in mental health. And we have to change the, so to speak, the soup we're swimming in toward the soup that says, what do we have? Why should we be ashamed of this? Don't we have to acknowledge this? Otherwise, the negatives inside of us, including the anger and frustration that I think promotes all the dysfunction in our political discourse, for example, all of this comes to the fore in sociological ways. So if we don't look at this, how likely are we to help people get help? And then if we do not do that, do we make everything worse in our inability to come to even a decision about what's factual and what's not factual? As we all, as a society, try and navigate things like racial issues or discrimination based upon gender or sexuality, or the climate crisis, how are we going to look at that if we don't look at what's going on inside of us? That often involves the. The anger and frustration that make people just say, need to be right. And like I'm saying, this is always where it goes. A lot of the dysfunction and the misery, most of it gets turned inward in people, but some of it does get turned outward. And I think we see the manifestations of that in the real degeneration of our discourse as a society.

What is the antidote to shame?

The antidote to shame is understanding. And I view the lancing of the abscess or the surgical excision of the abscess, that's the equivalent of shining a light on shame. That shame is so powerful. It's like the old. It kind of gets told a lot, but it actually happened. When I was a kid, there was a clothes tree in the room where me and my brother slept. And if you turn the lights off, it could look like a monster. And I know it was a clothes tree, but as a little kid, it gets scary. And is that really a clothes tree? It looks like a monster. It gets scarier and scarier and scarier. And then if I start screaming and crying and my parents come in and turn the light on, oh, I see that. It's just. It's not a monster. That's shame. If we turn our eyes away from it, which is exactly what it tells us to do. You can't share that even with yourself, let alone with someone you love, let alone someone professional. It's your fault that that happened to you. Right? You should have dressed differently. You should have not been in that place. You should have been better and someone wouldn't have hurt you. You should have been different and people wouldn't have treated you so poorly when you were way back when in school. These are the things that shame tells us. Like the devil on the shoulder telling us why we have to hide it away. And then it gets scarier and scarier. And when we go and shed light on it, I have never worked with one person. I cannot call to mind a single case. We're shedding light on shame all around it, right? Looking at all the dark corners of it and really bringing it to light in a process that has its moments of fear and misery, but also has its moments of levity and also has its moment of bringing good memories to the fore. Like being able to shed the light on that has never been anything but extremely helpful to the person doing it. But all the impact of shame tells us not to do that. And society really kind of goes along along with that. And the health systems that want to shuttle us through with a prescription for Prozac collude in that. So society colludes with shame in preventing way too many of us from ever getting a handle on our trauma, when it's actually not rocket science to do so.

So if you shine that light on shame and the person now realizes why they feel a certain way, the reason I feel so inadequate is because of these events or this event, and because of this inadequacy, I go and do this other thing. How do you change the feeling? So step one is understanding why. But then step two has to be you have to actually change that feeling, don't you?

Yes. The answer to that is you work on it across time. We live in a society that so wants rapid results and that's why we throw medicines at so, so many things throughout the whole field of medicine that we shouldn't throw medicines at. Oh, you're not healthy. Well, take this medicine. This medicine, this medicine. We don't say like, have it change your diet, exercise. I mean, things that you understand as well as anyone on the planet. Right. We don't do that. So we look to short term fixes and we all. Well, we know through just even basic education in brain biology that the neurons that fire together, wire together so if you and I picked a word out of the blue and we decided, let's say it over 500 times, then of course, we'll each be saying it tonight, it'll be in our heads tomorrow morning. What if we say that word 5,000 times? It'll be in your head next week. So if we say things to ourselves and we have a way of conceptualizing ourselves that we've overly reinforced, it will not go away overnight. But we don't tell people that. So when a person comes to an understanding milestone of like, oh, my God, the shame, is it mine? I was six years old. The shame is that person who hurt me, that part of how I make sure we end that session is all those thoughts and the feelings attached to those thoughts, and it's the feelings that make the difference are not going to go away. They will still be there with you. Because the only way they go away is they attenuate over time. And you've scored a victory today. That disempowers them that when those thoughts come like, oh, you're worth nothing and that was your fault, and if you'd been better, that wouldn't have happened to you. Like, okay, you say, wait a second, I don't actually believe that. I can't keep it out of my head. But I'm going to put you back thought. I'm going to direct my thoughts away from you more quickly. And there's a whole bunch of strategies around that. Then I'm going to put you back a little bit less powerful than how you came. And we don't, as a rule, we do not talk to people in that way. And then people feel terrible and they feel ashamed. And often their practitioners think they failed the treatment. And everyone now looks at this negatively because, oh, two, three, four weeks later, they're not better. There's no way on God's earth they were going to be better after two, three, four weeks. Something that's developed over years doesn't go away that quickly. But if we engage in that process and we take away what the fear. Because otherwise, if the person feels better, they have this aha moment, and then they go home and they're getting in bed, and the same thought goes, tomorrow's going to be better than today because you're not worth anything. No. Now they feel awful that that thing that happened today doesn't mean anything. So you have to prepare that person that absolutely you can be better, but it's going to take place over time. You don't have to be afraid when those Thoughts are still in your mind. I've had people I've worked with who say, started their treatment even before I met them, and they had among the most severe repeated negative thoughts and feelings inside of them. And they may have been doing really well for 10, 20 years, but you put them under enough stress and enough triggering and it'll still come in that, oh, you're nothing and you should kill yourself still comes into their mind. But now they know well enough, they'd be like, wow, that stuff dies hard. As one person said, that stuff dies hard. Not afraid of it one little bit. Because that person understands that he said that thing to himself a hundred thousand times and guess what? It's still going to come back every now and then. Does it mean anything? Doesn't have anything to say to that person, doesn't carry one little bit of information. And now that person isn't afraid of it, not saying, oh my gosh, am I going to hurt my. They know. But we have to educate people. And the mental health field doesn't put very much value in what gets called psychoeducation. Let's help you understand yourself. And I think that's also a lot of what I do, psychoeducation through the lens of understanding trauma. I think if you told me I could only do one thing, maybe I can't prescribe medicines anymore, I can't do depth psychotherapy, I can't use multiple modalities, I can only do one thing and I got to choose. I think I would choose psychoeducation about trauma because then, man, you arm people with knowledge they didn't have before and they can go help themselves. They can get help from people who are close to them, they can maybe get professional help, but it's that knowledge that helps us. Even if there's no professional help to be had, which is also a point of the book that I want anyone who picks that book up to be able to read their way through it and to end up on the end of it with knowledge and education they didn't have before. Because that, I think, is what is most impactful. And whatever a person does with that, which may be limited by time, circumstances, resources, all sorts of other things, they're now equipped to do something good with it. And the field generally does not do that.

When I think about our practice, I think about all of the dimensions of healthspan. So when I use the word longevity, I'm referring to two things. Lifespan, how long you live and health span, how well you live. And within healthspan, there's really three dimensions. There's a cognitive dimension, which I think most people kind of understand right how sharp is their brain. And most people can understand what the extreme loss of that looks like in the form of dementia. Then there's a physical dimension, the structural dimension, your ability to be free of pain, your ability to carry out activities of daily living, and your ability to do the things that you enjoy doing physically. And then there's an emotional component to this. Even though some people would touchy feely call this mind, body, spirit, I really like to think of it as cognitive, physical, exoskeleton and emotional. I think it's that emotional bucket that is the hardest one for us in our practice to help patients with. Because one, we don't have a great set of screening tools. We have really good screening tools for these other ones. And by the way, on the whole lifespan side, we have lots of great screening tools. We have biomarkers and MRI scanners and liquid biopsies and colonoscopies. I mean, we're very good at trying to identify the things that will end your life in a binary fashion. From a cardiorespiratory standpoint, we're not very good at identifying the things that are going to end your life emotionally. And in my book, which is obviously not written yet, but I mean, the draft is there, but I write about these four types of death. The first one being the one that people think of, cardiorespiratory pulmonary death, what I call death certificate death. But then I talk about these three other deaths. Cognitive death, the death of the ability of the brain, the decline of the ability of the brain with respect to processing speed, short term memory, long term memory, executive function, the physical or exoskeleton death or demise, which is basically that which leaves a person in pain and unable to carry out these activities of daily living. And then this emotional death and these three types of other death. Types 2, 3 and 4 often precede 1. In some ways, the perfect life would be a long life that just goes straight to type one death without detouring through type two, type three and type four. But tragically, that's almost never the case. And so we think so much about how to identify and treat type 2, type 3 and type 4, but by far the one in which we are the most limited is this identification of type 4. And part of it is, I think, shame. There's no question part of it is inadequacy of tools. For example, when it comes to identifying type 2 or type 3, let's use the physical one. We have so many ways that we assess people for movement and strength and balance and stability and stamina and all of these things. And usually once people are confronted with how bad they are, because almost always relative to our standards for where we want people to be, most people fall woefully short. But they can see, oh, this is where I should be if I subscribe to your ethos, that to be a really kickass 100-year-old, I need to be a doubly kick ass 50 year old. And here are the steps that we're going to take to train to get you there. But I've for years now wanted to think, how could we do that same sort of screening around emotional health and how would it be received and how would we then implement therapy? Because really, a person who's doing very well on the type 1, type 2 and type 3, meaning they have no chronic diseases, they have no acute diseases, their mind is sharp, their body is great, but they're a slave to some shame that's rooted in trauma. They can often have the most miserable life and really how long they live becomes completely irrelevant. In fact, it almost becomes paradoxically a curse. It's just more time to suffer. A lot of these people, of course, are not obviously suffering. So it's very easy to see a person living in a crack house with needle tracks in their arm and say, are you suffering? Yes. That's not a huge cognitive leap.

There are enough external markers that we can make that conclusion with a high.

Degree of, and they're probably self aware enough. But when you take somebody who's actually quite successful by all the metrics of the external world, they're successful financially, they have a wonderful family, all these other things it usually takes a bit of prodding for them to acknowledge and you have to be astute enough to prod and realize that actually all is not well.

Yes.

So I'm not a psychiatrist. How do I bring our evaluation of what I call type 4 death or demise up to the level of our ability to evaluate the other three?

The first thing I have to say is you've been kind enough to share with me some excerpts from the book. And when your book comes out, it will be anything but a day late and a dollar short. And I think you're talking about these, these aspects of life that are just so, so important in ways that we can understand, like am I taking care of myself in the way I want to, am I paying attention to my life in the way that I want to? And yes, that emotional aspect of it is the hardest to identify. As you said, there aren't serological markers for it. And often the truth of what may be going on is underneath the surface. And I would say that you already do the things there are to do. And we could talk about how might it be formalized. But I think of when you may refer someone to me. And why is that?

I guess I would say this. I think we do a better job than most. I guess what I'm really getting at is why can't we be doing better? Why is it that there are some patients whom I suspect there's an issue, but as I broach it, there's complete denial, or there's other patients who on the surface will accept it, but then we can't get them to engage in it.

Right. The processes that you're going through. So again, what do I think you're doing? And you can tell me, does this make sense? I think that you're looking for people whose actual behavioral choices are running countercurrent to what they're presenting for. And people are presenting to you because they want to be the healthiest they can be. So it's a little bit, maybe the health systems are less like that. People are presenting us with problems. So you will see if someone presents to you, the reason I'm here is I want to be as healthy as I can be. And then you see that they're not actually behaving that way or they're behaving in a way that kind of thwarts that. And then that will trigger like, ah, something is going on here. Right? Because otherwise why would those vectors not all be heading in the same direction? Good mental health is always consistent with simplicity in all of us. So if I would like to be healthy and I come to a health assisting resource, one would presume I'm going to act in ways that assist that resource in assisting me. Pretty straightforward, right? If we're not acting that way, then it points like there's something going on that's not consistent with that sort of simple, almost common sense understanding of how to make our lives better. And that will point towards something in the mental health spectrum which the vast majority of times has its roots in trauma. So if you see people running countercurrent to their stated goals or the second, I think there are two occasions on which we see people coming from your practice. The other might be if on discussion the person is sharing something about their inner world that's not consistent with what you're necessarily seeing on the outside. And then their sharing of that dissonance then leads to ah, there's something going on here that it's affecting them emotionally even if they are still trying to be healthy. But there's some toll that's taking then under the surface that you want to understand better and guide in the right direction. And the thought would be we could deploy that in sort of formalized manners in our medical health settings. So the person who really wants to stay alive because they love their grandkids, but they have diabetes and this is their third hospital admission in two years, right? And you say, okay, that person doesn't want this to happen, they like their life and they have their ground to these reasons of being healthy and staying alive, but they can't act that way. And to look at that and say maybe there are logistical barriers, right? Maybe there are non trauma related barriers to them getting to care, taking medicines, we can look very hard at that. And then very often I think where that process can arrive at is there's something that's preventing that person from taking care of themselves. And then there is the light bulb that says, ah, there's something here for the mental health aspect of helping or if and actually talking to someone whose life appears to be going well on the outside. But like is your inner world consistent with your outer world? And there are ways of formalizing this potentially in your own practice setting, but then in the broader settings of non mental health helping. So look for vectors that run countercurrent to the person's stated and healthy intention and try and get some assessment of what's going on in the person's inner world. Because even if things are going well in the outer world, but these problems are there in the inner world, they represent risks for the future. Again, I come back to it's not that hard to do. And I think that you're just reflexively doing this because you're in a sense applying common sense in the practice. If there's something here that seems outside of the fold I'm operating in, that seems mental health, then you make a referral. But the health, health systems in our society as a whole can be doing this to help people because it's not that hard to take stock of someone's inner state if you, if, you know, if you sit down and talk with them and you establish the right rapport or to call out when they're acting countercurrent with their stated intentions. And a lot of times the general medical systems kind of push that under the rug because they don't know what to do about it. So they keep trying to treat the diabetes as best they can with some knowledge in their head that like this lovely person who wants to be healthy isn't really on board with this. But if you don't know what to do about that, or the last 10 referrals you've made to mental health haven't yielded anything because three months down the road the person got a Prozac prescription and they're no better, then there's a sense of futility to it. And again, I think if we come back to well grounded common sense approaches, it's not all that complicated and it doesn't have to be that esoteric.

Do you think there will be a day when shame is out in the open? Because, I mean, that's really what this comes down to. You have the stigma of trauma and then you have the vector of shame that works so effectively at keeping it in the dark. What does a world look like in which the light switch gets turned on and shame has to retreat to the corner and cower as opposed to let its cape sit over that which needs to be exposed?

I think a big part of that is an education process in our societies.

And when you say education, what do you mean? Is this something that occurs in schools? Is this something that occurs in medical schools? Is this something that is for doctors only? I mean, should police be aware of this? I mean, how broad a net do you cast?

I think you cast a very broad net and I think it's not that hard to do that. So I think it starts in early education. When you talk about what goes on in people when they feel bad, when something makes them feel good, what happens inside of you, what do you do with that feeling? Help the bully understand why he or she is bullying. When we're in first or second grade, let's help that person understand and look at that person.

How would that be done? I mean, that would require teachers now understanding this, right?

Yeah, I think we do educate the professionals, we educate the doctors, we educate the teachers. I mean, there's so much that we, we do in the education processes that I don't think I'm saying, well, let's bolt on some process that tries to turn everyone into a therapist. But there's so many things that are done. You think about in medicine, like how many checklists, how much paperwork is done that's utterly and completely non contributory and everybody knows it. Why not an approach that's not paperwork intensive or time intensive, Right. That just looks at, look A part of trying to understand somebody is thinking about them through this framing and structuring the mental health resources so that there is a place to send someone. There's a place where you can have basic conversations about what's going on inside of them that then gates the care. There are ways we can do this that involve pretty basic education. That can change. Again, this idea of the whole soup that we're swimming in, where we start with early education and we run that through educating professionals, educating police, educating legal systems. There are mental health courts now, they're not nearly as widespread as they should be, but we are trying to educate doctors in the legal process and the education process, but we're not prioritizing it with a sense of urgency. It can be different, but we've got to look at it and we've got to say, yeah, this is worth paying attention to. Is this what's in large part or in very significant part driving that we have now overwhelmed 100,000 drug deaths in this country over the course of a year. Why do we not feel a sense of urgency and want to look at the way that we provide help and to say does what we're doing that drives doctors to burnout, which is a term that I can't stand. I mean, when I grew up, burnout was a negative term to say about somebody, oh, they couldn't handle it, and now they're just in a corner smoking cigarettes, doing their own thing. That was an insult to someone. And now we level that at doctors who are often traumatized by the health systems that they work in and the unreasonable expectations and that they're treating charts and computers all the time and don't have enough time with their patients. Like, why do we not look at this and say, has this gone mad? That we spend more money than any developed country on healthcare, yet we have the worst outcomes and we're the worst about things that involve direct contact with humans, preventive aspects of healthcare treatment over time. Why can't we look at this with a sense of urgency that says, oh, this isn't working? And then I think at the other end, people who other people look to and have a sense of respect for that will talk about their own trauma, as in some very small way, like I'm trying to do and you do, and Tim Ferriss has done, and even Stephanie Germanotta. So Lady Gaga, who is kind to write the forward for the book that she talks about her humanness, that we all, no matter who we are, are susceptible to this. So from the one end People who have any power whatsoever and authority need to not shrink away from this. So if I'm giving a talk to a bunch of doctors, I'm not going to pretend that I don't have any trauma. So yes, we need, we, I think, have a responsibility to be open and honest about the things that have impacted us. If we have any public presence whatsoever, let alone if a person has a big public presence, if that can be done safely and reasonably for the person, of course. So that's one aspect of it. And the other aspect is, the most important is on this grassroots level of changing how we frame mental health in the world around us and starting to get us curious about it. At very early stages of life. When that bully tells you that you're lousy because of what you look like or where you come from, what does that make you feel? And let's start looking at that reflexive sense of shame. Okay, can you stop and think about that? You feel bad when that happens and what happens next? Well, you feel bad about yourself. Okay, let's put a full stop there. That person's hurting you because he feels bad about himself. So then you start to put a barrier between the reflexive shame and the person feeling bad about themselves. Because how many people don't actually logically feel bad about themselves, but they do actually feel bad about themselves? And it's the feeling that matters, not the facts. And we've got to start looking at that because that is the plain and obvious truth that pervades the society around us. And we are doing a very poor job of developing understanding in us as individuals at any stage of life and as a society. And I can't believe that we're not seeing the dysfunction in the social rifts that we're having in the, the ineffectiveness of the whole of our medical system. These are big, all encompassing aspects of our society. And we see, hey, these things are not going well. And if we look at the roots of it, I think it's clear where a lot of it is coming from and also what we can do about it. Which is why I feel the book is ultimately uplifting. I mean, I'm pointing out problems, but I'm not pointing them out in some way of like pointing them out and then, well, we don't know what to do about it. I mean, I'm pointing out solutions that I think are quite simple and well grounded. And of course, if we just follow them through, that's resonating with people because I think it does resonate with common sense.

A Moment ago you alluded to a statistic that I think for many people is just almost impossible to fathom, which is the United States has just for the first time ever surpassed a 100,000 person mortality for a 12 month period. So 100,000 people have overdosed in the United States for the first time in 12 months. Do you see this as an epidemic of trauma and shame or do you see this as really just a new escape valve for it based on the availability of cheap and unfortunately highly potent opioids?

I think it's a combination of both. And I think the data tells us that, that more and more people are feeling desperate and disenfranchised. They're feeling like, look, I can't make my way in the world, whatever my chosen route of endeavor is, I can't make a living in, in that I can't support a family, in that I can't get ahead, I can't feel good about myself. And we see that in aspects of almost the entire service industry, which has changed to a place where people can't have careers that then support their lives and support a family like was the case even 20 something years ago. We see that even people who have good jobs, who feel like, okay, I finally got my way for I worked hard enough, I have a good job, that often that job is, is running them ragged in a way that they can't take care of themselves and they can't take care of their families. And they feel the same desperation as the person who doesn't have a job. And this desperation builds anger and frustration and resentment and all these other symptoms, depression and panic that spin off of it and that makes it much more appealing to soothe in the short term. That's a basic psychological fact of human beings. The more pain you're in in the short term, the more you're going to choose a short term solution solution without any consideration to the long term. I mean, if I'm absolutely desperately miserable and you've got something that can make me better right now, I'm not going to ask what that may do to me tomorrow. So we have developed a society that has become more and more and more hard hearted towards people's attempts to make their way in the world. And I think we see that with the response to the pandemic of I'm going to respond, respond in the way that I want and I don't really care about you. And we've seen enough of that that I cringe at times at our inability to even have basic compassion for others, which of course, isn't everyone, But I think that's present in society in ways that it wasn't before. And I think it's reflected in the rhetoric and the dialogue that's acceptable that not that long ago the way people often behave who have a public presence would have led to censure by everyone that would say, hey, I don't even care that you're advocating for what I want or even for me directly. Like, I can't support you if you're going to behave that way, talk that way, denigrate people that way. We've moved far away from that. And we need to look at what are we doing in the world around us. How are we handling ourselves and are we indirectly promoting the. This ethic of not really caring that leads to the desperation that leads people to soothe with drugs. There's a very macabre. It's not even a joke, it's a tragic atrocity, right, that people will say, oh, you know, I've gosh, I have four people who are drug addicted in my pregnancy, I'm going to see this afternoon. Or 10 people, right? And it's not who it used to be be because before it was people who had sifted down to places in society where society has really turned their backs on them. Now it's people from all walks of life. And we see that socioeconomic, demographic, educational, demographic, geographic, demographic, racial, religious, ethnic concepts. We've gone beyond that where now we're all menaced by this because there's often a desperation to soothe that. There wasn't that shot through every demographic we have. And if we continue to turn away from that fact, then we continue to look at statistics like that and say, oh my gosh, how horrible. Okay, we don't do anything about it, which is a tacit acceptance of it. If we don't look at what are we doing to people that drives them to desperation, then we're not going to make that statistic better. And how much has gone on behind closed doors in the pandemic, how much violence, violence behind closed doors, neglect behind closed doors, drug and alcohol abuse behind closed doors. Are we going to look more at this or are we going to just pay lip service to looking at it while we don't actually change anything? And then we'll be going, oh my gosh, it's so terrible. It's three years from now. That number's 140,000. Well, if we don't really care now as a society, we just want to marvel at the number and say how bad it is and do nothing. Well, it's exactly where we're going to go. That's why the number has been increasing, right? I mean, it's not rock rocket science to say that either. You just extrapolate that line ahead. And that gets worse and not better. Unless we look at it in a way where we accept like we got to do something different. Because this is staggering in the human misery that it speaks to. Not just 100,000 people lost, not just, I mean, what about all the people who love those 100,000 people? What are we doing? Which is why when people would say, oh, sometimes I will get approached like I am in a. I am doing something that is very niche, like I am interested in trauma, right? No, this is not a niche, right? You get up to numbers like that, there's a cascade through the population. And it doesn't have to be like this, that our burdens of trauma just grow and grow and grow. We should be appalled by that number. Appalled enough to do something about it.

Paul a lot of times we treat people based on the symptom of their trauma, or we at least categorize them that way. And this is even within the lens of helping people and acknowledging their trauma. So, for example, addiction is a very common manifestation of trauma. And the most obvious of those, or at least the one that probably gets most people's attention, would be substance addiction, alcohol or drugs. But, but there's work addiction, there's process addiction, there's gambling addiction, there's sex addiction. There are actually lots of other types of addictions, but we could bucket those as addictions. There's codependencies, there's anger, perfectionism, other means of control. We talked about eating disorders. It seems that one way to think about this is treating people together who have similar end states. So you go to a 12 step meeting because if it's AA, it's people with alcohol, if it's Al Anon, it's family members of people with alcohol, if it's na, it's narcotics, if it's sa, et cetera, it's sex, has anyone ever thought about doing the opposite? Which is rather than take everybody whose issue is alcohol addiction and having them come to a meeting, which, by the way, I'm not advocating against, what if we bundled people together through the common lens of what the trauma was? Is that something that's ever been thought about? And would that be more or less efficacious than the current approach? In other words, you have a meeting which has lots of people in it who have Very different manifestations of their trauma. You're going to have someone who's addicted to alcohol, someone who's a workaholic, someone who's a rageaholic, someone who's a completely codependent, someone who's got debilitating anxiety, someone who's got debilitating depression. But what they all have in common is they were completely neglected by their parents. That's their common thread. Would there be any advantage to doing that or is it better the way we typically think of doing it?

Yeah, I think there's a huge advantage to that. And when at one point I was medical director for a clinic and we had programs running for helping groups, by and large it was all around substances. But I wouldn't separate it by what the substance was. I think we even get that. Fine, now we're going to separate by what the substance.

Alcohol versus narcotics.

Right? And even at that level, let alone at the higher levels of this person is angry, this person is addicted to unhealthy foods. There's so many ways in which the addictive processes can take hold of our brains in order to provide some short term sense of control or short term relief from the desperation of feeling out of control. And when we parse that out too much, then again we're just trying to check the boxes and we're telling that person that what you have this thing that is in a sense your burden to carry is so much about you, right? I'm an alcoholic and I'm a rageaholic. And just the very language we use about that is often so stigmatizing. That's the thing that's bad about you. That's often the message. Again, not always, but that's often the message that it sends. As opposed to none of us come comes out of the womb an alcoholic or a rageaholic or addicted to unhealthy foods. Think of like, look what's happened to us along the way that leads us to this place. And that's how we make a search for commonality. So we have a set of processes that want to further parse things out. We're so overly reductionist that oftentimes we would see where the person who was an alcoholic would feel like, I don't want to sit in a room with a person who's addicted to cocaine as if there's nothing in common. As opposed to like, yeah, what is in common? Because I knew the health histories of those people, right? Because I was the medical director of the clinic and I would say, right, what is 80% commonality as a driving force amongst everybody is trauma. And that's just here. If you step further back, you see that across the things that we get short term relief from from at the expense of our long term health. And the over reductionism I think is a facet of wanting to just put things in little buckets and then gaining some satisfaction from that. But okay, now all it is, is in a bucket. And actually being in that much of a bucket, like a marble that goes down is like, now you can't get to it or you can't get to what's real about it. Instead of like what's going on in a lot of people say at least is trauma. Can we put those people together and look at trauma, which ironically is what the real sophisticated helping resources around trauma are doing. I mean, that's often what say the bridge to recovery is doing. It's looking at like, hey, what is your trauma? Okay, now let's go forward from there. But that's because they're bringing a sophistication to it. And people who do that work just reflexively know that they know that that's not different. You can look at people who are addicted to one thing versus another and you're not finding massive differences between them. And the aspects of our, the science of it all catching up with it shows that it's hijacking the same machinery in the brain and you can't tell the difference. Not like one substance looks different from another in the brain or one thing a person is addicted to for relief of distress. So it's like we know all of it, but we have these entrenched ways of looking at it through the lens of how medical care is or, or how society views it. And we're so far beyond the science, and I will say, to say a fair amount, that if you're in a very well defined field of medicine, like say cardiology or so, where we kind of know how to assess people, how to understand people, there's a lot of data behind the interventions. If you're practicing even just a couple years ago, that's not okay. And one will identify that. And that's not okay. Right. And we'll have to change that. But in mental health, the practice within individual practitioners and the systems can be antiquated by a half a century or a couple thousand years in some cases. And we don't come in and look at that. There are programs that are taking care of people for opiate dependence that don't even talk to them about a medicine that you can get a shot of that prevents you from overdosing when you leave. It's somehow okay not to even talk about that because we let all of this lag behind. And yes, part of it is, I think, how the field has handled it, and the science isn't as well developed, but it's not like there's no science, and it's not like there's no obviousness to what we could be doing that we're just simply not doing. And I think a big part of that is the stigma, the shame that we don't want to come in and look at all of it and say there's an obvious here that we're just not paying attention to. Because if the shame is shot through humans, then it is also shot through the humans who are making those decisions around resource allocation. And how do we approach the helping.

Process Changing gears for a second Paul, the final thing I want to ask you about is the role of two substances in particular, psilocybin and mdma, both of which I've talked about in previous podcasts as they pertain to trauma. I'm curious as to what your experience is with this and maybe more importantly, what is your optimism around these two molecules, both of which are really moving quite along a pathway towards a clinical approval, a legalization for clinical use. In the case of mdma, it is for, in fact, ptsd. So kind of curious as to whether you see that as an amazing adjunct to what we're talking about, or a slight adjunct, or potentially less.

I see it as among the brightest, shining hopes for the future. And I think the data, both from decades ago and the more recent data and the clinical experience in trials and the firsthand report tell us things that are so incredibly powerful and that fit with a lot of what we've thought about and understood about brain biology and about psychology. There's a way in which it provides so much greater potential for understanding and helping. And of course, the process is in place so that these very, very powerful tools can be understood and deployed safely and effectively. And in the context of all of that, I think that the hope is immense. A story I'll tell sometimes to try to capture that is Where I grew up was close to the Delaware Raritan Canal in colonial times. It ran between New York and Philadelphia, was part of a network, and I was always fascinated that artifacts would be found, somebody would be fishing and find a vase or something. It was a maze, these barges went up and down and like, what's in there? And people would find things. And that was interesting, but then at some point in time they drained a whole section of it. And when the section was drained, my goodness, what they found and what they saw. And it's the same kind of analogy that I think the helping powers of these substances are so strong that they can get us to places of really seeing what's going on inside of us us and shifting how those brain pathways which have been so changed. And again, the science tells us this, this is not esoteric. We have more science that is similar to what the CAT scan can do for the appendix to see that being able to do that with these helping modalities allows for understanding and is so predisposes to and is permissive of change in ways that can let people reorient much, much faster. So I think there is a potential here for even a revolution within the field. But we have to safely and effectively incorporate those arrows into the quiver. Then we see of course, what is often seen, which is many of the people or organizations wielding that have the magic amulet of like I am the source of the helping resources do not like this. So we see some aspects of traditional psychiatric care that, that don't like this. And I think that's through a sense of threat that I think the power of these resources make a lot of the tools that I wield seem maybe a little bit paltry in comparison. Now, that's not always the case. And if that is the case, wonderful. There are new powerful tools coming to the fore. We need to approach it, those of us in Western medicine, through a lens of, of being respectful of what that is and wanting to understand the new modalities and approaching it from a lens that says, look, if I'm going to help people or I'm going to hold myself forth as knowing how to do so, then I better know what all the arrows in the quiver are and understand them enough that I can either deploy them or I can understand who can deploy them in a way that does justice to the person coming in the door. If I'm coming in the door for help, I don't care what it is. I want the person who's going to help me and have other all the possible arrows in their quiver. And I think we can get to a place of incorporating this. But again, society and the helping systems have to bend a little bit to acknowledge the incredible potential. And then we work towards integrating instead of splitting. And we're in a societal mode in this country that's very much splitting, whether it's sociological, it's political, even medical. Again, I come back to the basic theme of. I think it's trauma that leads us to reject new helping resources because they may be threatening to our power within a discipline. And that by regrounding to really the first principles of knowledge and of helping, then I think we again come back to an urgency to ground ourselves to the basic common sense of understanding everything that can be helpful and having all of those arrows in the quiver of health systems or of, to the extent possible, individual practitioners.

Paul, as always, it's great to sit down with you and especially in a case like this where it's not just me you're talking to, but so many other people who I suspect will really benefit from this. Tell people again the title of your book and other places they can look to find resources.

Sure. The title of the book is the Invisible Epidemic. And you can find it if you just Google me, Paul Conti, or the clinic I work in, which is Pacific Premier Group. You'll come up with links that talk a little bit about the book or the principles contained they're in. And there's so many good helping resources around. NAMI is one of them.

And. Sorry, is that nami? What's that?

Yeah, so N a m I.

Okay, Nami.

So a great access to resources, often on a local level. There's so much help to be had, and some of that help we can access in our own homes, we can access through people that we love and who love us. We can access by thinking about what's going on inside of us and others. And I think that's such a part of the message that I want to deliver, that it just isn't esoteric. And if we ground to what's really going on inside of us and paying attention to it, and in a sense being brave enough to face it, because we see hope in facing it, that we can begin a process of really helping ourselves and others. And I've just seen that unfold so, so many times, including in myself, that I really believe in it. And I'm so glad that we've had this conversation that is about some of the real big picture of it and the more kind of rarefied medical aspects of it. And I think a real understanding of it runs the whole gamut, but is ground in that simplicity of what's really needed and what's important to help ourselves and to help other people. And I so appreciate you having me on and having such a good friend who's also such a good colleague and helps this discussion unfold in a way that really helps get the message out there because we all need the message.

Thank you, Paul.

You're welcome.

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Sam.