Peter Attia MD190 - How to heal from trauma and break the cycle of shame
CHAPTERS
- 0:02 – 5:09
Paul Conti's work and path from consulting to psychiatry
Peter Attia welcomes Paul Conti, who describes his clinical practice and consulting work. He explains how a consulting career in New York and his clinical rotations in medical school led him to psychiatry.
- •Conti is a clinical psychiatrist who runs a clinic with about 15 colleagues
- •He also consults on how brain function affects people personally and professionally
- •He worked for a consulting firm in New York before medical school
- •In his last year of medical school he saw psychiatry as a way to combine medicine with understanding people's lived experience
- 5:09 – 16:00
A brother's suicide and the reflexive shame of trauma
Conti recounts a mostly stable first half of life followed by major traumas, including his brother's suicide when he was 24. He describes the shock, the guilt, and how shame drove his family inward without words to talk about it. Attia shares a similar story about a friend.
- •His sense of self was thrown off by traumas arriving after a stable upbringing
- •The family was in shock and disbelief, and each member coped differently
- •Shame is a reflexive response to being traumatized and pushes people inward
- •His mother became depressed and isolated, which changed the course of her later life
- •He says we lack the words and the permission to describe trauma's immensity
- 16:00 – 19:42
Bifurcation after trauma and the turn to medicine
Conti explains how, after his brother's death, he lost confidence in himself, drank too much, and wallowed in guilt. A little therapy helped him ground himself again and strengthened his drive toward medical school. He frames trauma as something that can narrow our horizons or, understood well, strengthen our resolve.
- •Trauma caused a bifurcation in how he felt about himself, including feeling incompetent
- •He was becoming less healthy and drinking too much
- •A little therapy helped him reconnect with his confidence despite the stigma
- •He says trauma's consequences beckon us to limit our horizons, leading to depression, panic attacks and substance abuse
- 19:42 – 28:28
Psychiatry training: Stanford, Harvard, and the loss of presence
Attia asks how psychiatry is taught, and Conti describes training that teaches facts well but often fails on rapport and presence. He contrasts Stanford's neurobiology focus with the psychological depth he gained at Harvard. He criticizes a field drifting toward brief appointments and medication.
- •Much of what he learned as a resident should, in his view, be taught in elementary school
- •Diagnosis has moved from narrative descriptions to numbers
- •He calls much current practice "polishing the hood" when something is wrong in the engine
- •Stanford gave him strong biology, while Harvard and a mentor filled in the psychology
- •He uses neurobiology and psychology together through being a real person with patients
- 28:28 – 34:48
The DSM and why trauma is overlooked as a root cause
Conti and Attia discuss the history and rigidity of the DSM. Conti argues it catalogs symptoms rather than causes, so trauma underlying depression, anxiety, OCD and addiction goes unexamined. He says treatment fails when no one takes a trauma inventory and the system leaves patients worse off.
- •The DSM began as phenomenological description and became rigid, serving research and billing
- •PTSD criteria exclude real vicarious trauma that doesn't fit the definition
- •Conti says depression, anxiety, OCD and addiction are often undergirded by trauma
- •He describes handoffs reduced to diagnostic codes
- •He says emergency rooms and 15-minute appointments often leave people worse off
- 34:48 – 47:55
Defining trauma: acute, chronic, vicarious, and individual susceptibility
Asked to define trauma broadly, Conti says it is anything that pushes coping skills beyond their limits and changes how the brain functions. He lays out acute, chronic and vicarious forms, individual variation, and the multiple-hit idea. He also describes epigenetic changes that can be passed on to children.
- •Trauma pushes coping skills past their limits and changes brain function
- •Neuroimaging and gene expression changes show these effects are real
- •Chronic trauma includes neglect and systemic racism
- •Vicarious trauma, such as from following distressing news, can produce the same symptoms as acute assault
- •He suggests thinking of "circumstances" rather than events, and says he has prescribed "no more news"
- 47:55 – 1:03:14
Finding trauma's roots: from symptoms to the "why"
Conti explains how he came to see that he was treating the roots of problems rather than symptoms, using the image of trauma seeds falling into different soil. They discuss residential trauma facilities and eating disorders. They also discuss why trauma lacks biomarkers and why individual heterogeneity makes it hard for medicine to study.
- •Conti says he realized he effectively had "all trauma cases" and that helping people understand why was what mattered
- •Trauma facilities focus on understanding a person's history rather than on a PTSD label
- •Conti says trauma approaches 100% as a root of eating disorders
- •Attia notes psychiatry lacks biomarkers and faces heterogeneity in how people respond
- •Conti cites epigenetic research as scientific support, while saying the approach is not that complicated
- 1:03:14 – 1:14:18
Why trauma goes unrecognized: ACE scores, comparisons, and a patient's story
Attia raises the ACE questionnaire and how siblings can respond to neglect in very different ways. Conti explains that people underreport trauma because of shame, minimization, and the sense that it was too long ago. He tells of a woman whose daughter died and who denied having trauma although it drove her symptoms.
- •Checklists are one data point and cannot replace a human who sits with the patient
- •Siblings in the same family can develop very different outcomes from the same neglect
- •People dismiss their trauma by comparing it to others' or saying it was too long ago
- •Conti says trauma changes the instrument we use to understand our trauma
- •A woman who denied trauma began to grieve once shame was addressed, because self-blame blocks grieving
- 1:14:18 – 1:28:36
The abscess analogy and the hurdle to seeking help
Attia explains how an abscess forms and is treated, and the two compare it to walled-off trauma. Conti links the walling-off to evolutionary survival instincts that spin off modern symptoms. They discuss how psychiatry palpates the abdomen where it could use a CT scan, and how to lower the barrier to care.
- •An abscess is a walled-off infection, and treatment can make a patient feel worse before better
- •Avoidance and hypervigilance evolved to keep us alive but now spin off symptoms like drinking and panic
- •Conti says patients have one problem, not several, and that trauma is the common source
- •Talking about it often brings relief even in the first session
- •Knowing why therapy hurts makes the pain more tolerable, and the aim is truth rather than just feeling better
- 1:28:36 – 1:37:57
Shame as the main impediment to healing
Attia asks what stops people from doing the work even when a trauma explanation is offered. Conti says rapport and a holding environment matter, and that the first three answers are shame, shame, and more shame. He describes telling physicians about his own trauma and seeing them recoil, and connects shame to wider social dysfunction.
- •Rapport and a holding environment are the main predictors of therapy success
- •Conti says he and his colleagues acknowledge their own trauma
- •Shame is the primary henchman of trauma and attracts alcohol excess and a negative internal dialogue
- •A third of 300 physicians recoiled when he spoke of his trauma and psychiatric care
- •Unaddressed trauma feeds anger and degrades social discourse
- 1:37:57 – 1:45:30
The antidote to shame: understanding, light, and time
Conti says the antidote to shame is understanding, comparing it to turning on a light to reveal a clothes tree rather than a monster. Attia asks how the feeling actually changes, and Conti says it takes sustained work over time. He argues for psychoeducation about trauma so people know that negative thoughts fade slowly and need not be feared.
- •Shame tells us to hide, and shining a light on it has never failed to help, in his experience
- •Neurons that fire together wire together, so reinforced thoughts take time to attenuate
- •Patients should be prepared that negative thoughts may return and carry no information
- •Practitioners and patients often think treatment failed after a few weeks, which Conti says is unrealistic
- •If he could do only one thing, he says he would choose psychoeducation about trauma
- 1:45:30 – 1:57:07
Emotional healthspan and screening for the hardest dimension
Attia describes healthspan as cognitive, physical and emotional, and says emotional health is the hardest to screen for and help with. He describes four types of death and the emotional one. Conti suggests looking for behavior that runs countercurrent to stated goals and for dissonance between inner and outer worlds.
- •Attia says emotional health lacks the screening tools the other dimensions have
- •Someone externally successful can be miserable because of shame rooted in trauma
- •Conti suggests noticing when behavior runs countercurrent to stated health goals
- •He also suggests probing whether a person's inner world matches their outer life
- •General medicine often pushes this aside when it doesn't know where to refer
- 1:57:07 – 2:04:08
Bringing shame into the open through education and openness
Attia asks what a world look like where shame retreats. Conti calls for broad education from early schooling to professionals, police and legal systems, and for people with a public presence to speak about their own trauma. He criticizes healthcare spending and burnout, and frames the book as uplifting because the solutions are simple.
- •Education should start early, such as helping a bully understand why he or she bullies
- •Educating doctors, teachers, police and legal systems need not mean turning everyone into therapists
- •Conti names Tim Ferriss and Lady Gaga as people who have spoken openly
- •He argues that the feeling of shame matters more than the facts
- •Conti says he sees the solutions as simple and grounded in common sense
- 2:04:08 – 2:10:06
Overdose deaths and society's growing desperation
Attia raises the over 100,000 annual overdose deaths and asks whether it reflects an epidemic of trauma and shame or an escape valve. Conti says it is both, driven by desperation, economic pressure and declining compassion. He argues the problem now spans every demographic and warns it will worsen unless society acts.
- •Conti says people feel desperate and disenfranchised, even those with good jobs
- •The more short-term pain, the more people choose short-term soothing
- •He sees declining compassion and acceptable public rhetoric as contributing
- •Addiction now cuts across socioeconomic, geographic and ethnic lines
- •Merely marveling at the number without acting implicitly accepts it
- 2:10:06 – 2:17:29
Treating addictions by common trauma instead of by symptom
Attia asks whether people could be grouped by the shared trauma behind their different addictions and behaviors. Conti agrees and says that in a clinic he directed, he saw trauma as roughly 80% commonality across substance groups. He criticizes over-reductionism and how mental health practice lags behind science.
- •Attia proposes grouping people with different symptoms by shared trauma, such as neglect
- •Conti sees a huge advantage and says separating by substance only checks boxes
- •Language like "alcoholic" or "rageaholic" can stigmatize
- •He says addictions hijack the same brain machinery
- •Some opiate programs don't even mention a shot that prevents overdose, in his view due to stigma and shame
- 2:17:29 – 2:27:21
Psilocybin and MDMA as hope for trauma treatment, and closing resources
Attia asks about psilocybin and MDMA, and Conti calls them among the brightest hopes for the future, with the caveat of safe deployment. He uses a drained canal as an analogy and says traditional psychiatry's resistance may stem from threat. He closes by naming his book and resources like NAMI.
- •Conti sees these substances as potentially revolutionary, if used safely and effectively
- •The drained Delaware Raritan Canal illustrates seeing what lies beneath
- •He says some in traditional psychiatry resist these tools out of a sense of threat
- •Practitioners should know all the arrows in the quiver
- •His book is Trauma: The Invisible Epidemic, and he points to NAMI and his clinic's resources
