190 - How to heal from trauma and break the cycle of shame

1. 0:00 – 0:10

   Intro

   1. PAPeter Attia0:00

      [upbeat music] Hey, everyone. Welcome to the Drive podcast. I'm your host, Peter Attia. [upbeat music]

2. 0:10 – 3:29

   Paul’s background and unique path to psychiatry

   1. PAPeter Attia0:10

      Paul, amazing to be back here in person with you. It's, uh-

   2. PCPaul Conti0:13

      Thank you

   3. PAPeter Attia0:14

      ... it's been way too long.

   4. PCPaul Conti0:16

      Yes.

   5. PAPeter Attia0:17

      Uh, 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-

   6. PCPaul Conti0:26

      Yes

   7. PAPeter Attia0:26

      ... constantly. And now that we don't really travel that much-

   8. PCPaul Conti0:29

      Right

   9. PAPeter Attia0:30

      ... it's mostly phone calls.

   10. PCPaul Conti0:31

       Right.

   11. PAPeter Attia0:31

       But-

   12. PCPaul Conti0:31

       We got to spend so much time together, and I do miss that, too. And it's just really wonderful to see you.

   13. PAPeter Attia0:36

       Yeah.

   14. PCPaul Conti0:37

       And I so appreciate you having me here and spending time with you and family. It's wonderful.

   15. PAPeter Attia0:42

       Well, I, I'm excited to talk about your book, of course.

   16. PCPaul Conti0:45

       Thank you.

   17. PAPeter Attia0:45

       Um, but I think e- even though a lot of people have heard you on the podcast before, because we did s- we sat down probably three years ago, um, I'd probably take the assumption here that a lot of people are also coming to you or hearing about you here for the first time. So, uh, l- let's tell people a little bit about who you are. What, what's your day job? What, uh, what is it you do?

   18. PCPaul Conti1:07

       Sure, sure. I'm trained as a psychiatrist, and a big part of my day job is being a clinical psychiatrist. I also do some consulting work along the lines of understanding brain function and, and how, uh, 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.

   19. PAPeter Attia1:44

       And 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?

   20. PCPaul Conti1:54

       Yeah. I think around the time in the clinical rotation part of medical school, probably into the last year when I realized that you could, like, really be a doctor and, and, like, u- understand medical things and how they impact people and, and really kind of be grounded in that aspect of, of, like, practicing medicine, but also trying to understand people's experiences of life, right? 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, to, like, all the things one learns about life just through going through it and, and, and really help people in that way. And, and that just had such tremendous appeal as a, a sort of, um, widely encompassing way of, of approaching trying to be of, you know, trying to be of help.

   21. PAPeter Attia2:42

       Now, you, of course, didn't come to medical school in the typical way. You were not a pre-med. You didn't, you know-

   22. PCPaul Conti2:48

       Right

   23. PAPeter Attia2:48

       ... you, you had been out and working for four years or so before medical school-

   24. PCPaul Conti2:52

       Yes

   25. PAPeter Attia2:52

       ... if not more. Um, so what is it that, uh... What were you doing, first of all, before you made this decision to go to medical school?

   26. PCPaul Conti2:59

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

   27. PAPeter Attia3:28

       So

3. 3:29 – 19:42

   A personal tragedy that shaped Paul’s understanding of trauma and resulting feelings of shame and guilt

   1. PAPeter Attia3:29

      y- we've spoken about this obviously before. You, you write about it in the book. There are a handful of events that occurred during your, um, your upbringing, um, your adolescence that I think ultimately shaped how you now think about this thing called trauma.

   2. PCPaul Conti3:44

      Mm-hmm.

   3. PAPeter Attia3:44

      You want to talk about some of those things?

   4. PCPaul Conti3:46

      Sure. So I had a really interesting course of life in the sense that in kind of the first half of my life, there, there weren't major traumas. So I was fortunate to have a, a stable family system around me and to develop a, a, a, a pretty stable sense of self, um, which is much easier to do if there aren't big traumas. And, and then in the second half of my life, there, there started to be some very major traumas. And to experience the traumas after having developed an orientation to, to myself and to the world, um, that had been free of them was very, very striking. And I think it, it put me in a place to, to see, uh, even though I didn't completely understand them, but, like, 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, like, 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, you know, the, the fortune to have a, a, a 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'd kind of gotten through those formative stages without that.

   5. PAPeter Attia5:09

      How old were you when your brother committed suicide?

   6. PCPaul Conti5:12

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

   7. PAPeter Attia5:16

      And at the risk of asking an obvious or maybe not so obvious question, how shocked were you at that time? Because-

   8. PCPaul Conti5:27

      Yeah

   9. PAPeter Attia5:27

      ... you know, you hear these tragedies of someone commits suicide, and everybody around says, "Well, it was just a matter of time, you know? It was-"

   10. PCPaul Conti5:34

       Right

   11. PAPeter Attia5:34

       ..."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-

   12. PCPaul Conti5:46

       Right

   13. PAPeter Attia5:46

       ... not see this. And so where on that spectrum were you and, and I guess by extension your family?

   14. PCPaul Conti5:53

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

   15. PAPeter Attia7:43

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

   16. PCPaul Conti7:54

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

   17. PAPeter Attia9:40

       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, w- what, what is... You know, I, I, I have, I think about the stories in my life of people I grew up with who, for whom suicide was a, was an issue. So, uh, I mean, I had a girlfriend in college whose mom committed suicide.

   18. PCPaul Conti10:06

       Right.

   19. PAPeter Attia10:06

       Had a very close friend in high school whose dad committed suicide. Had another girlfriend in high school whose dad committed suicide, and um, one of these had a very tragic outcome. The one, there was a, a friend whose dad committed suicide, he later committed suicide.

   20. PCPaul Conti10:22

       Mm.

   21. PAPeter Attia10:23

       Um, and that was an example of where I thought to myself... A- 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.

   22. PCPaul Conti10:35

       Mm-hmm. Mm-hmm.

   23. PAPeter Attia10:35

       Um, 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, he just doesn't seem like he's doing well." And, um, I said, "Well," you know, like, and I, to this day, I just feel so ashamed over this. You know, I said, "I'm gonna be home in like three weeks."

   24. PCPaul Conti10:55

       Right.

   25. PAPeter Attia10:55

       Uh, you know, "I'll, I'll connect with him then." But, you know, at that moment in my life, nothing seemed more important than graduating first in my class.

   26. PCPaul Conti11:03

       Right.

   27. PAPeter Attia11:03

       And anything-

   28. PCPaul Conti11:03

       Right

   29. PAPeter Attia11:03

       ... that was gonna stand in the way of that-

   30. PCPaul Conti11:05

       Right
4. 19:42 – 28:27

   The current state of psychiatry training and need for improvement

   1. PAPeter Attia19:42

      So when you think back to your residency, um, you s- you, you stayed at Stanford after med school for the first part of your residency before-

   2. PCPaul Conti19:50

      Yes

   3. PAPeter Attia19:50

      ... going to Harvard. Um, you think back to those first couple of years, what, 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. You know, in many ways, if I think back to my residency, um, it was, you know, 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. Um, 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.

   4. PCPaul Conti20:43

      Right.

   5. PAPeter Attia20:43

      In other words, using words seems harder than using a needle and suture. So what, what is the process of education in a psychiatric residency program?

   6. PCPaul Conti20:55

      Well, there, there's lots of learning of facts, right, of course, around neurobiology and around medicines and around different modalities of therapy. So I think in that way it's probably similar to o- other fields of endeavor. Um, but then there are the less tangible aspects, um, that are the most important, right? 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, I think across the board often fails us. Um, and I think part of that is, is sort of the world, the society we live in and the world of modern medicine. I was very, very struck, and I con- continue to be, um, over these past twenty years, of how so much of, of what I learned, say, as a second year psychiatry resident, I think we should be teaching people in elementary school, right? And, and I really do mean that, about like just how we respond to the world around us, right? I mean, the idea that, you know, 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 receiving end, right? And how does this all work in our brains, right? And how do logic and emotion clash in our brains and, and e- and emotion wins over logic, yet we're taught that we're logical creatures, right? Like things like that, I was in some sense actually quite, quite incensed at a whole education process that doesn't prepare us to like live life by telling us the basics of what goes on in our brains, right? 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, 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, so this trend away from describing someone in a narrative. You say, "Well, how would you diagnose that person?" Right? You know, years ago it would be in a narrative. You know, you would talk about who that person was in, in at least a couple of paragraphs, right? And that's by and large gotten reduced to a number, right? And the, in, in trying to regiment itself, um, i- in a way that I think is overly rigid and serves the, the field's interest and desire to integrate with the rest of medicine, we l- 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, right? Which do in many cases make sense, but the boundaries were put forth in a way that was often about e- eliminating the realness of, of presence with someone. And, 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, right? If we, if we realize, look, we're gonna help people through, 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, right? That, that I did find in my training process, but I didn't find in the, 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, right? And while I learned a great deal and I, 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, a field that often in its training and its interaction with patients ignored the crucial point of, of realness of the experience of the other person

   7. PAPeter Attia24:35

      I want to think about kind of the differences between these two programs you, you trained in, right? Because you did half of your training at Stanford and half at Harvard-

   8. PCPaul Conti24:43

      Mm-hmm

   9. PAPeter Attia24:43

      ... 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, um, for the second half of your training, and, and how did that impact the way you practice today? Because in some ways you have a luxury of having seen two very different, um, approaches to psychiatry.

   10. PCPaul Conti25:08

       Yes.

   11. PAPeter Attia25:09

       A, a more sort of biologic and a more clinical, more of a sort of Freudian view versus a, a more, uh, I don't know how, what you would describe the, the one at Stanford, but it seems to me a more of a neurobiology view.

   12. PCPaul Conti25:20

       Yes. Yes.

   13. PAPeter Attia25:20

       Um, both of which strike me as having huge benefits-

   14. PCPaul Conti25:25

       Yes

   15. PAPeter Attia25:25

       ... if they can be integrated.

   16. PCPaul Conti25:26

       Yes.

   17. PAPeter Attia25:27

       Was it received that way f- by you?

   18. PCPaul Conti25:29

       I think I didn't comple- I didn't understand, uh, certainly not at the beginning because Stanford is so, uh, neurobiology based, right? So, so the medical and neurobiological approach to psychiatry, uh, i- is, is just really the f- among the finest points of that program, and I was lucky to learn a lot of, of neurobiology, neurochemistry, function of medicines, aspects of the different parts of our brain and how they communicate amongst one another to generate o- our perception of reality and at times the, 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, of being a psychiatrist, of the unconscious motivations in us, of the sort of 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, uh, Dr. Marianne Batteraco, to whom I'm, I'm eternally grateful, um, 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 [chuckles] psychology knowledge and then really helped me to get that knowledge once I was there from, from, from the people who could really teach it to me. And, 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, and then the way, like how do you put the rubber to the road of that is by, by being a real person with the person that you're trying to help, which, which I, I think is the way I approach the field and the people that I work with, we, we approach the field the same way. Um, but like we're really the, the instrument right through which all of that comes and, and hopefully helps somebody. So, so that maybe is in one's personality or, you know, you just kind of realize that, that like, oh, when I'm being sort of more rigid in a certain way, like I'm less helpful. And, and if I'm 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 gonna be a trauma person. I'm gonna write a trauma book." I, I saw it was undergirding, you know, a, a, a very, very high percentage of everything that I was trying to treat. So, so the 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, [chuckles] right, unless I had had that experience that really exposed that.

5. 28:27 – 34:48

   The over-reliance on outdated metrics and lack of attention to past trauma as an impediment to patient care

   1. PAPeter Attia28:28

      So when was the first edition of the Diagnostic and Statistical Manual published? How, how, how... Uh, I don't know where this fits in the evolution and history of psychiatry.

   2. PCPaul Conti28:38

      1948. Somewhere i- uh, late 1940s. I think 1948, but in that, in that range.

   3. PAPeter Attia28:44

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

   4. PCPaul Conti28:58

      That- that's what it evo- has evolved to. In the, in the initial versions of the DSM, it was describing in a sense the phenomenology of like wh- what is this particular diagnosis like? What, what are the aspects of it? What's, what's felt or experienced by the person, and what's seen from the outside? And, and then there were sort of clusters of symptoms that, that would then lead one to s- to think that that diagnosis fits, right? Which acknowledges, in a sense, the unique aspects of human beings, that if we get too rigid about that, right, w- we start serving, in a sense, the manual, right, instead of the person. And, and in many ways, the, the DSM evolved as a way of allowing for research criteria to say, okay, we wanna be calling a diagnosis sort of the same thing-

   5. PAPeter Attia29:47

      Yeah

   6. PCPaul Conti29:47

      ... if we're gonna 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, you know, you have this very, very thick book that could give everyone multiple diagnoses, right? 'Cause it's kind of designed to do that, and then come up with a number that justifies the 15-minute appointment, right, in which the person has no hope of, of actually being understood in any way, because you can't do that in 15 minutes, right? And-

   7. PAPeter Attia30:13

      And, and we're at the DSM 5 right now, correct?

   8. PCPaul Conti30:16

      Mm-hmm. Yes

   9. PAPeter Attia30:16

      We're in the fifth generation of this manual, which seems to get updated about every 15 or 20 years.

   10. PCPaul Conti30:21

       Yes, it's the fifth generation. There are technical revisions in between, but yeah, it's really evolved to something that I think is so rigid that it, um- in many ways works against the clinical care that we are trying to achieve. And, and again, I'm all for criteria and being able to have descriptive language and, and research criteria, but we've gotten to the point where it often gets called like a, a bible, right? Which I think is, is like a very unfortunate word to use in many ways. It, it implies that there's something in that book that, that actually tells you what mental health problems are and, and what they are not, and some of the criteria really make no sense. So, so for example, someone who, who has sort of vica- vicarious trauma that they're experiencing but not in an occupational framework doe- does- doesn't meet criteria for a PTSD diagnosis, which has come to mean 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, 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, 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, a resultant symptom of that too.

   11. PAPeter Attia32:11

       So outside of post-traumatic stress disorder, PTSD, how often does the word trauma appear in the, uh, DSM-5?

   12. PCPaul Conti32:22

       Well, it, I mean, 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, is looking to take an inventory of signs and symptoms, right? It's not looking at causality, right? And, and that is a problem, right? Because so much of the depression that I see, so much of the anxiety spectrum disorders, obsessive compulsive disorder, for example, um, abuse of substances and addiction or alcoholism, right, is, is undergirded by trauma, right? And trauma changes that person's experience of, of life to a place of fear and vulnerability, right? And then that drives the subsequent problems. But if we're not looking at w- 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 that haven't been helped by three, four, five, six courses of treatment, right? And they're then often labeled as, quote-unquote, "failing," right, the treatment. And, and very often the treatment has never taken a trauma inventory, and it is trauma that is driving the substance use, right? 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, right? Because, you know, because you're, you're... nothing ever works out for you. And, and, you know, this wasn't that person's belief in themself 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, right? So, so the fact that we're not looking to etiology, right? And, and I think that, 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?" "It's a two nine six point four four with a three O nine point eight one." And you're like, "Oh my goodness," right? We're talking about human beings here, right? 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.

6. 34:48 – 47:55

   Defining trauma: various types, heterogeneity, and effects on the brain

   1. PAPeter Attia34:48

      So let's define trauma as broadly as we can, because there's probably somebody listening to this right now who's thinking, um, okay, trauma could be an injury.

   2. PCPaul Conti35:01

      Mm-hmm.

   3. PAPeter Attia35:03

      Um, 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, uh, I can see how that would be traumatic. Um, 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, what trauma means?

   4. PCPaul Conti35:36

      Yeah. 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, a chronic sense of denigration, right? But it creates these feelings inside that then change the, the, the functioning of our brain, the communication within our brain among the various parts, right, in a way that 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, you know, that's identifiable in modern science when we can see the changes in, um, in space-aged neuroimaging, right? That, that shows how the connectivity in the brain shifts, or even the, the fact that trauma changes the, 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 the limits. And our view of trauma comes through this history of seeing trauma through the lens of combat, right? Because it's sort of the most obvious way to see it, right? 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, we look to acute trauma because it's the most obvious, right? And as you said, if, okay, there's a suicide, and gosh, the family members are traumatized. Like, and we can, we can see that, right? But what we, 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, right? It differs by genetic characteristics. It differs by early life experience. It differs by, for example, how finely tuned one's emotional compass, compass is. It dr- it differs by the chronicity of trauma, so the sort of multiple hit hypothesis, which 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, right? So we tend then to paint with this broad brush that ignores, right, the richness of human diversity, right? And, and how we are impacted differently by different things, right? And then it also ignores that not all trauma is chronic, or sorry, is acute, right? That, that there are traumas that are chronic. So you think of the, the trauma of neglect, right? There, there's, uh, the neglect of a child is not defined by an acute incident, right? It's defined by the impact upon that child of the neglect over time, right? The same thing with, with the aspect, for example, of systemic racism, right? Of, of a person who gets messages over time that they're less than, right? 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, a species that we can be empathic with one another, right? We can experience the emotions of another person, right, in a way that's connected as if they're our own, right? But the other side of that coin is we can be traumatized by what happens to other people, right? And sometimes that might be someone we're very close to, right? Or it might be a person who develops such a strong interest because they're, 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, with that. And then, you know, for example, a, a, a person who was so deeply impacted by the crisis in Syria, right, that then develops post-trauma symptoms, right? And, and that person, like, never left their home in the United States but was so appalled a- and so distraught by what was going on and, and didn't know to, like, divert their, uh, 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, right? So, so the, the truth of human experience reflects the diversity of how we can be traumatized in acute, chronic, and vicarious ways and that how tra- 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 follow patterns. And, and of course, the discipline of psychiatry following patterns and identifying patterns is very, very important. But we also need to acknowledge that we're different, and we, we can't understand what's going on inside of a person without paying attention to that actual person.

   5. PAPeter Attia41:06

      You know, using that example, um, 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's the event or events, which again can be acute, chronic, or experienced by others that you witness.

   6. PCPaul Conti41:25

      Maybe circumstances. I would think of that as circumstances, right? Because event still in my mind applies something, implies something more acute, right?

   7. PAPeter Attia41:32

      Mm-hmm.

   8. PCPaul Conti41:33

      As opposed to circumstances, which could be an acute event or something chronic or vicarious.

   9. PAPeter Attia41:37

      So using that extreme example of, of a person who, you know, 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, these feelings we're talking about. [lips smack] So when you, when you-- I mean, 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

   10. PCPaul Conti42:21

       I think it just excludes them because they just don't meet the criteria for what validates the trauma, right? Which is interesting. So the book has to validate the trauma, right? And like that doesn't really make sense, right? I mean, we should be looking at people and saying, do, do you present with the signs and symptoms of trauma that has pushed your coping skills over the limits, right? Do, 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 hypervigilant? Do you feel less safe in the world about maybe yourself or people that you love? Like these are clearly identifiable things, right? And, and if we're taking stock, like what is your human experience, right? And has something changed in you? Then the idea is we would honor that, right? And I wouldn't say, "Well, oh, wait a second, that, that happened to you, but you were vicariously traumatized in the course of something occupational. So now, okay, so you get-- I'm gonna put the stamp of approval on you. Wait, you, you-- well, that happened 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 you're fearful about your children in ways you weren't before. Wait a second. That wasn't occupational. Now, now we're not-- now you don't get the stamp of approval," right? I mean, the, the, the idea is we have to anchor to the truth of human experience because it's, it's not that extreme that people are traumatized by vicarious things. I mean, a-and I absolutely see this. I mean, I've written many more times than I can count on a prescription pad, like, "I'm gonna write you a prescription," and the prescription I'm writing is no more news, right? Because I see that that person's health, or maybe that person I've known for years, their health has really deteriorated over a couple months of paying attention to something so intensely distressing. And we've had more, you know, than we can shake a stick at, right, in, in recent years that you could pay attention, you know, to, to the point of like utter despair, right? And then who, 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 atten- intense attention to, to traumatic things they're seeing in, you know, in the world around them, and now they have a syndrome, right? So w-we're not doing justice to that if we're, we're making a set of criteria that try and treat us like robots or machines instead of, hey, like these are human beings, and we have to know like what's come before in your life, right? Where were you at when you experience an acute or chronic or vicarious trauma? And if we, if we look at the manifestations, 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 at someone without really trying to understand, then you-- we, we often even the first step we take down helping pathways is misguided. And then is it a 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 a s- a overly strong or exaggerated statement that accessing mental health help often leaves someone feeling worse. And I'm not trying to be over, 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 fifteen-minute appointments. How are you supposed to understand and help someone? So I think the entire system is misguided towards this, you know, how little money can we spend in the short term? How can we get human beings out of the equation, right? Because human beings cost more money to deploy than medicines, right? We, we are misguiding ourselves in a way that's, that's away from common sense, and we do often leave people worse than when we found them. A classic example being go to-- going to a hospital and trying to get help, where maybe fifteen or twenty years ago when a, a person I was taking care of might be in crisis, I would think, "If I don't send that person to an emergency room, like that would be malpractice," right? Like they, 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 gonna wait thirty-six hours, right, forty something hours before they see someone. They're gonna be put in a place that's gonna feel very shameful and very stigmatizing, right? There, you know, there's a locked room, and people are watching that person, you know, i-in a way that makes them feel, um, like they're being treated like they're crazy when they're, they're in distress. And when they finally get help, you know, 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, there are not enough beds in emergency rooms, in mental health units. There's not enough time with practitioners. I mean, the fact that 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.

7. 47:55 – 56:49

   Importance of finding the roots of trauma and understanding the “why”

   1. PAPeter Attia47:55

      Where in the last twenty years did the, did the sort of 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, two thousand and seventeen. Um, and not surprisingly at that time, I didn't really know what you were talking about. Um, I only thought about it in the most literal sense, which is You know, 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.

   2. PCPaul Conti48:36

      Mm-hmm.

   3. PAPeter Attia48:36

      And you had already been sending patients to, um, you know, inpatient facilities, residential care facilities that specialized in trauma care.

   4. PCPaul Conti48:48

      Right.

   5. PAPeter Attia48:49

      So w-when did this occur for you? When did you start to integrate these other modalities? When did you, when was the first time you sent a patient to a residential program that specialized in trauma such as, you know, the Bridge to Recovery or-

   6. PCPaul Conti49:03

      Right

   7. PAPeter Attia49:03

      ... a place like that?

   8. PCPaul Conti49:05

      I would've been s-sending patients to, to residential facilities for trauma since very early on in my career, but not having the understanding. Like, you know, like when you, when you do anything for, 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, you know? And as I got, I think just learned more and got more experience and more ability to spend more time with people and, and, and try and just always have a venue where I could try and understand that person, right? Led me to realize like, "Wait, I'm doing the same things all the time," right? 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 under- to, I'm trying to help the, you understand why, right? Because that's what's going to make the difference. And maybe along the way we can treat symptoms, right? Maybe I have you on a couple of antidepressants, right? Or even someone who has psychosis, something like so dramatic, right? 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, like I'm doing this all the time, is, is trying to help people understand where the problems are coming from because that's how they get better, right? Which is the same a-as what I saw in myself, right? You know, this was anger, frustration, resentment, you know, underlying depression. Like all of these problems were in me, right? And, and, you know, a very negative, uh, and oppressive internal dialogue, right? And in my own psychotherapy of exploring this, right? You know, 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, right? That you're doing this. And so I saw in my own, the process was to help me, right, 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 those roots are the, the, the seeds of trauma falling into a soil that lets those seeds grow and trying to understand what, what is that soil inside of you, right? How is it unique to you? How does it follow patterns that impact all of us, right? What was that seed? How has it grown? I, I at some point realized, "Oh, that's what I do," right? That's what I'm doing. And I stopped thinking, oh, like, how many depression cases do I have or how many is... I, I didn't think about that. I said, "Oh, I kind of have all trauma cases," right? And, 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 like really came together in a way that this, this lens of trauma seemed not like, oh, some esoteric discovery, but, oh, I'm just rooted back to the obvious, right? It rooted back to the obvious, which, which really some of the older literature in describing human behavior knew all the time, right? But just wasn't at the forefront of the discipline in terms of its education and training.

   9. PAPeter Attia52:21

      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, of course, but-

   10. PCPaul Conti52:37

       Probably a pretty high percentage, right? Because trauma gets defined as does that person have PTSD, right? And, you know, people aren't gonna, not gonna s-even say all the things that would lead them to be diagnosed, right? Because they're ashamed of the symptoms, right? I mean, the role of shame is so huge.

   11. PAPeter Attia52:54

       But, but when you go to one of these facilities, and I've been to two of them, um, the word PTSD almost never comes up, right? It's, it's usually, "Hey, you know, 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-"

   12. PCPaul Conti53:13

       Right

   13. PAPeter Attia53:13

       ... "underneath the surface." So given that the facilities themselves don't position themselves as PTSD treatment centers-

   14. PCPaul Conti53:20

       Right

   15. PAPeter Attia53:20

       ... necessarily, although there are people there with PTSD, but that's just another-

   16. PCPaul Conti53:25

       Right

   17. PAPeter Attia53:25

       ... gr- you know. It's interesting to me that practitioners aren't more aware of this tool.

   18. PCPaul Conti53:31

       Right.

   19. PAPeter Attia53:32

       Let's, let's take something like an eating disorder.

   20. PCPaul Conti53:34

       Right.

   21. PAPeter Attia53:34

       Right? You, you take care of many patients with eating disorders.

   22. PCPaul Conti53:37

       Yes.

   23. PAPeter Attia53:37

       What fraction of those patients would you say have an underlying trauma as a significant contributory factor in their illness?

   24. PCPaul Conti53:47

       Approaches 100%. Approaches 100%. Even if you look at trauma through that appropriately broad lens, right? 'Cause 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 the actual truth of what causes the outcome. So the, the chronic trauma of immensely high expectations of self, right? Often placed upon self by self, but, uh, but often, uh, that process being aided and abetted by external forces, right? 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 i-immense s-senses of, of insecurity and of vulnerability. And, and people laboring under that for long periods of time can find an outlet for control. I mean, i-in many ways, that's often what the signs and symptoms of so many mental health, uh, uh, issues are, right? 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 by restricting what they eat, and they can control what goes into their bodies, right? And what are the roots of that? The roots of that are always trauma. I, I can't think of an eating disorder Um, 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. The facilities know because when you show up at a trauma facility, right, they wanna understand and treat your trauma, right? They're not concerned. Do you have the magic card of entry of PTSD, right? But because medicine, you know, how, how many times is this-- it gets said so often, but it's true, right? Of the doctors are treating the computer, the chart, right, the paperwork, right? That, like, so much of it is about does that person have trauma or not have trauma. I gotta determine if they have PTSD. Like, you know, it's, it- 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 fifteen-minute appointment or will pay for the medicine that's gonna treat the symptom but not the problem, right? That they're then become a gating mechanism. And, like, PTSD is some magic gating mechanism, right, 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, you know, the w- the world we live in says we 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, right? They talk about the, the reality and truth of what you've lived and, and what that has done to you in ways that are then counterproductive to your life, right? And, like, that's the truth and the realness of it as opposed to, opposed to a, a, a false, um, sense of surety that comes from all those guidelines and box checking that is, uh, d- really divorced from the human experience.

8. 56:49 – 1:08:13

   The major challenge of recognizing trauma in patients

   1. PAPeter Attia56:49

      It seems to me that part of the problem... I mean, there's so many problems to the recognition of this, right? The first is there's, m- you know, medicine works in, in the, in the sphere of biomarkers and, um, objective measures of, uh, illness or disease, right? So we can look at a biomarker like a person's ApoB or LDL cholesterol or a hormone level, and it's subjective. We, we can understand what that implies. Or we can look at a CT scan that shows an injury here or there. But, you know, psychiatry has none of these things, right? Psychiatry, you know, doing an MRI of a person's brain offers you no more insight into their plight or their suffering than, you know, rubbing a towel on their head and dumping some hot wax on it. Um, uh, you know, again, there are exceptions, of course. There are exceptions where, you know, certainly, uh, you know, a nutritional deficiency like a B12 deficiency or something that can show up in a biomarker-

   2. PCPaul Conti57:45

      Right

   3. PAPeter Attia57:45

      ... can explain a psychiatric illness, but, but for the most part, that's not the case. So that's sort-- I call that kind of macro problem one. I think macro problem two is the heterogeneity of the soil-

   4. PCPaul Conti57:56

      Mm-hmm

   5. PAPeter Attia57:56

      ... that you described.

   6. PCPaul Conti57:57

      Right.

   7. PAPeter Attia57:57

      Right? You could take one hundred individuals and simultaneously expose them to the same traumatic event, but without knowing what their antecedent history is-

   8. PCPaul Conti58:11

      Right

   9. PAPeter Attia58:11

      ... right? So what have-- what else has this person experienced? And, um, so in other words, what else has been dropped in the soil?

   10. PCPaul Conti58:18

       Right.

   11. PAPeter Attia58:19

       And without knowing the composition of each of their soils, you really have no idea how those one hundred people are going to react to an identical stimulus.

   12. PCPaul Conti58:29

       Right.

   13. PAPeter Attia58:29

       And that, of course, is very uncomfortable for medicine when... You know, it's uncomfortable for science, right?

   14. PCPaul Conti58:36

       Right.

   15. PAPeter Attia58:36

       If you think of Koch's postulates. Like, we really love it when we can say, "Add this microbe, get this disease."

   16. PCPaul Conti58:44

       Right.

   17. PAPeter Attia58:44

       "Subtract this microbe, subtract this disease." Like, you know, medicine is so good at that type of-

   18. PCPaul Conti58:50

       Yes

   19. PAPeter Attia58:51

       ... thinking, and it's like we don't have the t-- 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, the, again, the obvious, the lack of biomarkers, et cetera, the lack of diagnostic criteria, um, and the incredible heterogeneity of the individual and their history. And those are actually not the same thing.

   20. PCPaul Conti59:22

       Yes. And I think on the one hand, look, we need to acknowledge that complexity and also that lack of specificity, right? But on the other hand, there are aspects of that that I think simplify in, in ways that are very, very compelling, right? So, you know, in, in the book, I interview Stephanie von Guttenberg, who's a, a- an expert on the prevention of-- understanding and prevention of child abuse, and Darren Richarter, who's a professor at Stanford, who's done a lot of trauma work around trauma work and trauma research around the impact of trauma on identifiable markers and what that means, right? So for example, his work, uh, draws at times from the field of epigenetics, which shows that gene expression changes after trauma, and he was-- his testimony was instrumental in, uh, in, um, jurisprudence on an international level recognizing that, for example, rape as a tool of war, right, is not like a one-event criminal act, right, which was how it was being viewed. Okay, that thing happened on that day, right, in a way that circumscribes it. And the, the epigenetic research around trauma shows that not only is it not a one-event limited to a day, right, uh, experience, but that it carries on throughout that person's life, right? It impacts the society in which that person lives, and it gets passed on to the next generation, right? 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 kinda knew all this was true because we s- saw it obviously in front of us. Now we do have what science wants to have to, to, to hang our hats on, right? 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 100 people, right? Like, what is the trauma? Um, you know, a, 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 gonna be, you know, the majority are gonna be very deeply affected, right? Or there might be other kinds of trauma where you can only understand by really understanding that person. So, so, like, we do fit patterns, and we can m- 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, right? But we can understand it well enough to say, okay, it's actually not that complicated, right, to try and understand, like, what, what, what has your experience been, or what's going on inside of you, right? If you present as depressed, like, well, what's your history, right? And what are you saying to yourself inside, right? And has that shifted over time? Like, we can understand that in a way that says, do I, do I think that your brain is different because of trauma? It's like 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," right? So there's an aspect of this that's also kinda simple too, that we don't deploy because we're lost in the complexity of all those other things, all that box checking, and, you know, 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.

   21. PAPeter Attia1:03:14

       Are there, um, checklists that provide value? So for example, the adverse childhood event, the A- is that what it's called, ACE?

   22. PCPaul Conti1:03:23

       Mm-hmm. Yep.

   23. PAPeter Attia1:03:23

       Um, it's a series of questions, right? It's 10 questions, 20. How many questions is it?

   24. PCPaul Conti1:03:29

       I don't know. There are different versions that get u-utilized in different realms, and I'm not, I don't-

   25. PAPeter Attia1:03:33

       Okay. But it's, you know, it's, it's in-

   26. PCPaul Conti1:03:34

       ... even know what the standardized version is now.

   27. PAPeter Attia1:03:35

       Yeah, yeah, yeah, but it's in that ballpark. So sometimes these tests are really good at catching... They, they, they, they have a high positive predictive value-

   28. PCPaul Conti1:03:45

       Mm-hmm

   29. PAPeter Attia1:03:45

       ... but they seem to have a low negative predictive value.

   30. PCPaul Conti1:03:47

       Right.
9. 1:08:13 – 1:14:18

   How shame and guilt are barriers to treatment and healing

   1. PCPaul Conti1:08:13

      All the time. Absolutely all the time because, and this is really a crux of the messaging of the book, because w- trauma changes the instrument that we use to understand our trauma, right? Like, it's changing our brain, right? So i- so you comb- combine that with how much shame is evoked, right? And how hard it can be to discuss that, right? Because if we're ashamed of something, we don't wanna reveal it to somebody else, and we often don't know just because it's a professional. Is that person gonna feel okay about me, or are they gonna look at me differently because they see that shameful thing in me? Like, we feel this, and absolutely I felt this after my brother's death. I'm gonna go see this therapist. I don't even know this person, and, you know, w- what's he gonna think of me? Like, you know, here I, 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, I thought maybe, you know, she was gonna say, "Shame on you for what happened." Like, I didn't know, right? And I think that is the norm, which is why, like, we can't replace humans, right? Like, we kind of understand this, that we can't replace humans in our helping endeavors with, like, something that's computerized, right? So, or mechanized in some way. So, so sure, we wanna take inventories and, like, if, if we can, like, if it makes sense. Like, ta- take a, an inventory of trauma signs and symptoms, but realize that, like, you have no idea what that data means until you sit with the person, right? And, like, it, it's ... Why should it be strange to say that human beings are a necessary part of this helping process, right? 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 or, you know. I have a lot of data, and I'm like, "Okay, it tells me something, but I really don't know who, anything really about that person until they sit in front of me," right? Because once they sit in front of me, I can anchor that data to something, right? And, and very often what I, I started seeing over, you know, getting more experience in the field was when you talk 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 then I think that the last story in the book about the, the woman who, it was a true story, who 10 years later was 10 years younger, and I got her permission before writing it because I didn't, you know, I didn't ... That's not a composite, right? It's this, this person who just didn't understand, like, s- how her life had changed.

   2. PAPeter Attia1:10:48

      Tell, tell, tell the story.

   3. PCPaul Conti1:10:50

      So, so she ha- had had a tragedy in, in her life, and it was a 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 was so stark.

   4. PAPeter Attia1:11:12

      This is the woman whose daughter died.

   5. PCPaul Conti1:11:14

      Yes.

   6. PAPeter Attia1:11:14

      Yeah.

   7. PCPaul Conti1:11:15

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

   8. PAPeter Attia1:12:00

      H- how did she come into your care?

   9. PCPaul Conti1:12:02

      It was for other things, to, to, to treat some of the symptoms that had spun off, which is often the case. Like, oh, this person is depressed, or, you know, there's just so many things. I'm like, "Okay, that's, that's just the cart of entry." Like, maybe that I will find there a pure biological depression, right? But I've ceased to believe that that is what I will find because 20 years of doing this intensively has taught me differently. So then the, 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, right? 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, that, that, or a little bit better, right? That then brings her in where we look at what's going on in the roots that's affecting all of the leaves, right? 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, 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 didn't, couldn't see her own worth anymore. And you wanna see a, an absolute disjunction of oneself from a before and after, that will do it. And by understanding it, it could get better, right? Does it take away the grief? No. In fact, it lets her begin, it let her begin to process the grief, right? 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 if the grief gets walled off, right, 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, right? It brings the shame of, like, losing jobs and losing family and, and, you know, all the ways in which feeling bad about ourselves makes us feel worse about ourselves, right? So the i- 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, which is 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

10. 1:14:18 – 1:18:08

    How treating trauma compares to treating an abscess—a powerful analogy

    1. PAPeter Attia1:14:18

       Actually, I've always found the analogy of the abscess to be quite helpful, especially for folks who understand what an abscess is-

    2. PCPaul Conti1:14:26

       Mm-hmm

    3. PAPeter Attia1:14:26

       ... how it's formed-

    4. PCPaul Conti1:14:28

       Right

    5. PAPeter Attia1:14:28

       ... and what the implications are of it, right? So, uh, uh, for maybe folks who aren't familiar, an abscess is a, is a walled off infection. So, a, a, 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, um, this was even known hundreds of years ago when people were making long haul journeys across the ocean. You know, if you had a ruptured appendix in the middle of the Atlantic Ocean when you're halfway between Spain and the Americas-

    6. PCPaul Conti1:15:03

       Right

    7. PAPeter Attia1:15:03

       ... kinda SOL. Um, 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-

    8. PCPaul Conti1:15:16

       Yes

    9. PAPeter Attia1:15:16

       ... 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-

    10. PCPaul Conti1:15:29

        Right

    11. PAPeter Attia1:15:29

        ... and all the nastiness inside there, but it was sort of walled off. And if you could get this right, that person might just might survive. Now, they weren't gonna be perfectly healthy-

    12. PCPaul Conti1:15:38

        Right

    13. PAPeter Attia1:15:38

        ... um, but, but they'd survive.

    14. PCPaul Conti1:15:40

        Right.

    15. PAPeter Attia1:15:41

        [lips smack] Now, today, we still see people that show up with abscesses from a ruptured diverticulum or something like that.

    16. PCPaul Conti1:15:47

        Right.

    17. PAPeter Attia1:15:48

        Um, and they're not well. They're not dead though.

    18. PCPaul Conti1:15:53

        Right.

    19. PAPeter Attia1:15:53

        But they're just not well.

    20. PCPaul Conti1:15:55

        Right.

    21. PAPeter Attia1:15:56

        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.

    22. PCPaul Conti1:16:10

        Yes.

    23. PAPeter Attia1:16:10

        They have to acknowledge, "I have an abscess." Now, it's a lot easier with an abscess 'cause we have a CT scan that is stark. I mean, an abscess is an unmistakable thing. Uh, 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 gotta 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, uh, even though you're doing it in a manner to clean it up, the, 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 it's-- this is rarely a fatal event, but it's nevertheless, uh, uncomfortable. And in many ways, that just strikes me as a great analogy-

    24. PCPaul Conti1:17:14

        Yes

    25. PAPeter Attia1:17:14

        ... 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.

    26. PCPaul Conti1:17:32

        Right.

    27. PAPeter Attia1:17:32

        And three, the treatment is much harder, right? 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 gonna do all this stuff, and we're gonna 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.

    28. PCPaul Conti1:17:50

        Yeah. And I think as I'm listening to you, what, uh, it makes me wanna focus on is the really big hurdle, right? Because I think the abscess is-- it's really, um, it's a remarkably good analogy, right? Because the, the reflex is-

    29. PAPeter Attia1:18:02

        It saved you. The trau- Y- your response to the trauma-

    30. PCPaul Conti1:18:06

        Right
11. 1:18:08 – 1:22:00

    How evolutionary survival instincts create problems in modern society

    1. PCPaul Conti1:18:08

       Right. W- w- we're built to recoil and protect ourselves from dangerous things, right? Which is why i- if, if you think about trauma leading to avoidance and hypervigilance, right? And people become more afraid of the world and less likely to engage and less likely to take chances, right? 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, right? Like taking chances in, in good ways, right? That, that a person becomes much less likely to do that, right? And if you think about how these systems grew in us, right, that trauma raises a lot of negative emotion in us, and then we, we recoil to protect ourselves, right? And it may be that even a depressed mood or, uh, panic attacks and disturbed sleep, like this may all go hand in hand with hypervigilance and avoidance to say, "Look, that's, that is better than death," right? And when these systems grew in us, where a lot of the trauma that, that happened did tell you to stay close to home, right? You know, in humans, human development, right, and we're in small groups, and, you know, if you eat something that makes you sick, like never, never, never eat that again. And, you know. Or if you go over that hill and someone from another tribe attacks you, like, "Don't go there again," right? "Just stay closer to home." They're, they're, they're there for a reason, right? They're, they're part of the, the evolution of human beings psychologically, right, over time in order to stay alive, right? But then i- in the modern world, those things don't always make sense anymore, right? And that walled-off, say, psychological abscess, right, that is indeed better than death, is spinning off symptom after symptom, right? It's making that tendency towards a little too much alcohol soothing that that person, you know, does a couple times a year. Well, now they wanna do it a little more because there's a desperation in them, right, 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, right? Or that, that tendency towards avoidance is now they can't get out of bed or leave the house. Like, these are things I see all the time and, and often What brings a person to care is a symptom, right? Just like the person with the abscess might come to care because they're having night sweats or something.

    2. PAPeter Attia1:20:18

       Or they don't know they have an abscess. Exactly.

    3. PCPaul Conti1:20:20

       Right.

    4. PAPeter Attia1:20:20

       They, they just don't feel well.

    5. PCPaul Conti1:20:22

       Right. So, so the parallel is so strong there, right? And I think the difference is in the hurdle, right? That even though I might say, "Okay, uh, wait, now I'm gonna feel a little w- worse before I feel better? But like, oh, I see that bright thing on the CT scan, and you're telling me you're gonna go in and take it out, and I'm gonna 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, right? And the problem, I think, is in how high the hurdle is for, for trauma. And, and I guess, actually, I, I think the problem is, is, is twofold. It, it actually is in it's not as easy to recognize as the abscess, but I think that it should be, right? That our mental health methods of coping, uh, of helping, sorry-

    6. PAPeter Attia1:21:07

       Right. You, I mean-

    7. PCPaul Conti1:21:07

       ... should look for this

    8. PAPeter Attia1:21:08

       ... in, in, in looking for abscesses, we have 256-bit CT scanners that can produce a resolution of one by one by one millimeter.

    9. PCPaul Conti1:21:19

       Uh-huh.

    10. PAPeter Attia1:21:19

        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. I mean, you're, you, the, there's a huge ... I mean, I don't wanna 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.

    11. PCPaul Conti1:21:42

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

    12. PAPeter Attia1:21:54

        Oh, I completely agree. Yes, yes, yes.

    13. PCPaul Conti1:21:56

        Yeah. 'Cause the human brain has more sophistication than even that

12. 1:22:00 – 1:28:35

    First step toward healing: overcoming the fear of talking about past trauma

    1. PCPaul Conti1:22:00

       finest CT scan, right?

    2. PAPeter Attia1:22:01

       That's right.

    3. PCPaul Conti1:22:02

       So if we apply the, the trained human brain to say, "Look, I wanna try and understand what's actually going on in you," instead of saying, "Oh, oh, you're depressed. You check 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, right? But if we apply the human brain like we apply the CT scanner, right, then we will identify way more trauma and say ... Look, how many times I tell a person, "Like, here's the great news is you do not have five problems," right? 'Cause people will present saying, "You can't help me. There's no way you're gonna help me," right? "This has been going on in me for years, and I have f- f- four different problems," right? "How are you gonna help me?" Right? So here's the, the great news. Been going on for years because it's never been looked at, right? So it's not surprising it goes on for years. And you don't have four problems, you have one, right? You don't have depression and sleep disturbance and panic attacks and alcohol abuse, right, as entirely different problems, right? 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 were present after the trauma, right? And then that's not rocket science, right? So we could stop palpating the abdomen and bring in the equivalent of the CT scan or even better, right, the human brain, right? And then we can identify what's going on, and we can also decrease the hurdle. Like, why is it so daunting to get help for trauma, right? I mean, in many ways it is scary, right? Because the person often has been keeping it inside and, and I hear this all the time too. They're like, "I can't talk about that because ... " And then, 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," right? They don't realize, look at what it's doing to you because you're not talking about it, right? But when you can get someone to understand that, and often that comes already that's, 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, right? And I didn't lean across the table and say, "What?" Like, "Get outta my office." Like, things that people are afraid of. Like, I was afraid after my brother's death, right? Already there's an ex- people, this happens all the time, will say, "I feel better now," right? "I already feel better." Because b- uh, 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 my, my, that thing happened to my friend's child," right? Like, like, you know, th- they know, right? They know. But because of the shame and the idea of what are you gonna do with that, right? They don't know that there's helping resources. So we don't put it out there that there's helping resources, right? 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 gonna help, or they've already done it four times and it hasn't helped, right? So we create these barriers by, like so many things in modern medicine, by stepping away from, from common sense. Like, let's use the right helping mechanism. Let's use the, 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, right? They feel good about it like you feel good about doing something that's hard for you. Like, you know, like working out is really hard, right? But like, 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 w- that, that, you know, the, the, the whole group of us have together, like, it's not a miserable place to come, right? And people are often surprised by that, that, you know, this is supposed to be miserable. It's supposed to make them feel bad. And if you come to a place that's, like, just reasonably nice and you meet people who are like, "Hey, I'm in the soup with you too," right? Like, "I know things. I'm trained. That's why I can help you. But, but You know, I'm, I'm having the same problems

    4. PAPeter Attia1:26:13

       But don't you find that in the, in the short term it can be quite distressing to go back and revisit these things? I mean, uh, I, I think that's been more my experience than not, both personally and with others, that it, it can re- it really does feel a little bit like that abscess where-

    5. PCPaul Conti1:26:29

       Right

    6. PAPeter Attia1:26:29

       ... in the, in the days after that surgery, in that case, the, the patient actually looks worse.

    7. PCPaul Conti1:26:35

       Yeah, absolutely. Like, absolutely, yes. But because you know why and you know that it's helping you, it's much more tolerable.

    8. PAPeter Attia1:26:44

       Yes.

    9. PCPaul Conti1:26:44

       Right?

    10. PAPeter Attia1:26:44

        Yeah.

    11. PCPaul Conti1:26:44

        And this happens in my own therapy. I'll think, "Gosh, I've gotta talk about something from the past that is now being triggered," right? Like, something happens in my present, and it links me to a trauma of the past that, that, like, really shook my confidence and, like, now my anxiety level is higher, and I know it's gonna be hard to go in and talk about that. I know it, and I know it's gonna be painful, but I'm not af- I'm not afraid of it, right? Because I know that it's helping me, just the way that, that people perceive pain differently, right, in medical settings if they know why, right? And I, I saw a study you probably have seen around, like, gunshot wounds, right? And, like, people's pain being so different if they see that there's something, th- that there was some reason, right? Like, they're trying to help somebody, right? And now they know that, like, e- even though, like, this is terrifying, like, they're gonna survive it, right? And their level of pain goes down, right? So yes, it's painful, but the perception of the pain is this pain that threatens me, menaces me with destruction, right? Or is this pain that, although painful, is in the service of, like, doing right by myself, right? And that's often what we'll anchor to of, like, 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, that you're worthless, right? Like, that doesn't seem fair or right to me. You know, and I even sometimes y- you joke, or I don't know, have you, you been kidnapping buses of schoolchildren I don't know about, right? Like, is this it? That, that this, like, there's something to feel ashamed about here, but it's the person who did that thing to you, right? Or maybe there's nothing to be ashamed about here because, like, something just happened in life, right? And, and it's that change inside the person that gives us all the bravery to, 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, right? The purpose is to shift towards something that's true. Oh, and by the way, that true

13. 1:28:35 – 1:37:57

    Shame: the biggest impediment to healing

    1. PCPaul Conti1:28:35

       thing feels better.

    2. PAPeter Attia1:28:36

       What do you think are the impediments, um, to a, 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.

    3. PCPaul Conti1:29:06

       Right.

    4. PAPeter Attia1:29:07

       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.

    5. PCPaul Conti1:29:20

       Mm-hmm.

    6. PAPeter Attia1:29:20

       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-

    7. PCPaul Conti1:29:36

       Mm-hmm

    8. PAPeter Attia1:29:38

       ... th- they're, you, you get the feeling that they might not take treatment.

    9. PCPaul Conti1:29:43

       Right. Right. Yeah, I mean, I think the biggest problem, 'cause you said, "So what are the problems," right? And the biggest problem is presenting to a system, right, that is not looking to throughput and minimal short-term cost, right, as the primary metric of success, right? 'Cause that brings the frustration of not finding what's needed, right? And what's needed, of course, are skills that are learned through education and training, right? They're neurobiological knowledge and pharmacological knowledge and psychotherapeutic modality knowledge, right? But most importantly, it's, it's presenting in a setting where there can be what's called a holding environment, right? 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 wanna look down on us, and can help us hold the distress of it, right? And that's the commonality. Like, the psychotherapeutic modalities are so very, very different. But if you look at primary predictors of success, it lies in the rapport. Because the rapport, the trust, the mutuality that's generated is what creates that, again, that thing that's called a holding environment, which is like, I'm really, I'm scared of this and it's intimidating, but, like, I'm gonna come here and this is a safe environment and you're a safe person and you wanna help me, right? 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, right? 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 gonna carry that until the next time I'm gonna go back, in part because the person I go to for therapy makes me feel helped and understood, and I know that he's gonna carry it with him, and he wants to help me, and he feels a sense of respectful camaraderie in the, 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, right? And know that I'm gonna come back next week and I'm gonna make more progress. But our helping systems have to be set up to do that for people. Otherwise-

    10. PAPeter Attia1:32:03

        Let, let's assume those are in place.

    11. PCPaul Conti1:32:05

        Okay.

    12. PAPeter Attia1:32:06

        Let's assume that-

    13. PCPaul Conti1:32:06

        Big assumption though, right? Big assumption

    14. PAPeter Attia1:32:07

        ... 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, uh, you know, any of the other manifestations of trauma. What are the things that stand in the way of them accepting that information and moving forward?

    15. PCPaul Conti1:32:34

        First three answers are shame, shame, and more shame, right? That sh- trauma makes a reflexive shame in us, and that's what tells us to make the abscess, right? What's interesting is in the appendix example, the abscess happens because a biological pro-process happens, and now the appendix bursts, right? 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, like, that walls off. But the difference here is, like, the creation of that abscess occurs inside of us, right? Through, through our defense mechanisms, right? That say, "I've got to wall this off," right? "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." Right? So we do it to ourselves because that's what seems like the course of action that's safest, right? 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, right? 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, right? Which then makes it harder to get help, right? So shame, which is like the primary henchman of trauma, right, in my view, comes along with all these other accomplices. Like shame loves alcohol excess, right? Shame loves an internal dialogue that tells you that you're not worth anything. You're not gonna get anywhere, right? There are all these, these things that shame loves that we then cultivate in ourselves, and we pl- we apply to further walling off, further pushing that problem down. And that's why it-- 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, right? To look and say like, "Look, many, many, many of us have really significant trauma that is, that is, 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, right? I remember this was a bunch of years ago, but I was talking to a group of about three hundred physicians, right? From mixed backgrounds, mixed disciplines, and, and I said this, right? I said that I've had, like, really significant trauma in my life and, like, psychiatric care and psychiatric medicines have really helped me, right? And I could see out in the audience, like probably about a third or so is a rough estimate of people were like, like shocked like that I, I had said something that was so shameful, right? As if, you know, the next thing that was gonna happen is like someone's gonna fly through the air and tackle me, right? And, you know, pull my medical license out of my pocket and, and, and, you know, put me someplace where, where, where people go who need those things. And I said, "Look, this is a problem," right? Because I can see, and I hadn't planned on this, right? I, I hadn't planned. Like I, I, I said, "It's a problem because I see, like, a lot of you really recoiling from this, right?" And, 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, right? And, and I, and I think, in fact, being able to say it is what helps me navigate the world, right? But if we recoil from like, oh, you might need help, right? Or you might need medicines, like w-what, what is going on inside of us that means how likely are any of those doctors to get themselves help, right? And how likely are their patients to feel comfortable if they broach something traumatic, right? 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 fifty percent of complaints to general medical providers come from mental health conditions, right? I mean, the studies show, you know, a bottom of fifty percent and a ceiling that's significantly higher than that. So, 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, but you see that response even in mental health. Like some of those people who recoiled were almost certainly in mental health, right? And we have to change the, so to speak, the soup we're swimming in toward the soup that says like, "W-what do we have? Why should we be ashamed of this?" Right? Like, 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. Like, 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 don't do that, do we make everything worse in our inability to come to even a decision about like what's factual and what's not factual as we all as a society try and navigate things like, like racial issues or discrimination based upon gender, sexuality, or the climate crisis? Like how are we gonna look at that if we don't look at what's going on inside of us that often involves the anger and frustration that make people just say, "Need to be right"? And like I'm not saying this is always where it goes. A lot of the dysfunction and the misery, most of it gets turned inward t-- 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.

14. 1:37:57 – 1:45:30

    The antidote to shame and the need for discourse and understanding

    1. PAPeter Attia1:37:57

       What is the antidote to shame?

    2. PCPaul Conti1:38:00

       The antidote to shame is understanding, right? And I view the, the, the lancing of that aspect-- uh, sorry, the la- the lancing of the abscess, right? Or the surgical excision of the abscess. That's the equivalent of shining a light on shame. Right? That, that shame is so powerful. It's like, you know the old, um, this, it kind of gets told a lot, but it actually happened when I was a, a kid. Like, there was a clothes tree, right, in the, in the, in the room where I, my, I, me and my brother slept, right? And if you turn the lights off, it could look like a monster, right? And, and like I know it was a clothes tree, but as a little kid, like it gets scary, and is that really a clothes tree? It looks like a monster. It gets scarier and scarier and scarier, right? 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, right? And, and that's shame. If we, if we l- 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, right, let alone with someone you love, let alone someone professional, right? 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, right? You should have been different and people wouldn't have treated you so poorly when you were way back when in school, right? These are the, 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 where shedding light on shame all around it, right? Looking at all the dark corners of it, right, and really bringing it to light in a, in a process that has its moments of fear and misery, but also has its moments of levity, right? And also has its moment of bringing good memories to the fore. Like being able to shed the light on, 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 with that, and the health systems that wanna shuttle us through with a prescription for Prozac, you know, collude in that, right? So society colludes with shame in, in preventing, uh, way too many of us from ever getting a handle on our trauma when it's actually not rocket science to do so.

    3. PAPeter Attia1:40:12

       So if you shine that light on shame and the person now realizes why they feel a certain way, right? 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.

    4. PCPaul Conti1:40:41

       Right.

    5. PAPeter Attia1:40:41

       But then step two has to be you have to actually change that feeling, don't you?

    6. PCPaul Conti1:40:45

       Right. Yes. And the answer to that is you work on it across time, right? We live in a society that so wants rapid results, right? And that's why we throw medicines at so, so many things and throughout the whole field of medicine that we shouldn't throw medicines at, right? "Oh, you're not healthy. Well, take this medicine, this medicine, this medicine." We don't say like, "How about change your diet, exercise." I mean, things that you [chuckles] you know, you understand as well as anyone on the planet, right? We, we don't do that. So we look to short-term fixes, right? And we all-- Well, w- we know through our just even basic education in brain biology, right, that the neurons that fire together wire together, right? So, so if you and I picked a word out of the blue and we decide, let's say it over five hundred times, right? Then of course, like we'll each be saying it like tonight, right? It'll be in our heads tomorrow morning, right? What if we say that word five thousand times, right? It'll be in your head next week, right? So, 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, right? But we don't tell people that, right? So when a person comes to a, like a, a really say, an understanding milestone of like, "Oh my God," right? "The shame isn't mine. Like, I was six years old. The shame is that person who hurt me," right? That, 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, right, are not going to go away, right? They will still be there with you because the only way they go away is they attenuate over time, right? And you've scored a victory today that disempowers them, right? 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 you say, "Wait a second. I don't actually believe that," right? "I can't keep it out of my head, but I'm gonna put you back, thought. I'm gonna direct my thoughts away from you more quickly," and there's a whole bunch of strategies around that. "And then I'm gonna 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 like 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 gonna be better after two, three, four weeks. Like something that's developed over years doesn't go away that quickly, right? But if we engage in that process and we take away what? The fear, right? Because otherwise, if the person feels better, they have this aha moment, right? And then they go home, and they're getting in bed, and the same thought goes, you know, "Tomorrow's not gonna be better than today because you're not worth anything," right? Like no, now they feel awful that that thing that happened today doesn't mean anything, right? So you have to prepare that person that like, absolutely, you can be better, but it's gonna take place over time. You don't have to be afraid when those thoughts are still in your, in your minds. I've had people I've worked with who, say, started their treatment even before I met them, right? And they had among the most severe repeated negative thoughts and feelings inside of them, and they may have been doing really well for ten, twenty years, right? 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. Right? But now they know well enough, they can 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, th-think to himself 100,000 times. And guess what? It's still gonna come back every now and then. It doesn't mean anything. Doesn't have anything to say to that person, doesn't carry one little bit of information, right? And now that person isn't afraid of it, not saying, "Oh my gosh, am I gonna hurt my..." They don't... They, they know. But you, we have to educate people and, and the mental health field doesn't, doesn't put very much value in what's ca-what's called psychoeducation. Let's help, 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, I can't... 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 gotta 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, uh, 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, they're now equipped to do something good with it, and the field generally does not do that.

15. 1:45:30 – 1:57:06

    The emotional health component of healthspan

    1. PAPeter Attia1:45:30

       You know, when I think about our practice, um, I, I think about all of the dimensions of healthspan. So when I use the word longevity, I, I'm referring to two things, lifespan, how long you live, and healthspan, how well you live.

    2. PCPaul Conti1:45:45

       Right.

    3. PAPeter Attia1:45:46

       And within healthspan, there's really three dimensions. There's a cognitive dimension, um, 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.

    4. PCPaul Conti1:45:58

       Right.

    5. PAPeter Attia1:45:58

       Then there's a physical dimension, the structural dimension. Uh, you know, 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.

    6. PCPaul Conti1:46:12

       Yes.

    7. PAPeter Attia1:46:12

       Right? Um, so even though some people would touchy-feely call this mind, body, spirit, I, I, I really like to think of it as cognitive, physical/exoskeleton, and emotional.

    8. PCPaul Conti1:46:22

       Mm-hmm. Mm-hmm.

    9. PAPeter Attia1:46:22

       I think this is the... I think it's that emotional bucket that is the hardest one for us in our practice to help patients with.

    10. PCPaul Conti1:46:31

        Right.

    11. PAPeter Attia1:46:31

        Because, one, we don't have a, a great set of screening tools.

    12. PCPaul Conti1:46:37

        Right.

    13. PAPeter Attia1:46:37

        We have really good screening tools for these other ones. And by the way, on the whole lifespan side, we have lots of great speen- screening tools. We have biomarkers and MRI scanners and liquid biopsies and colonoscopies. I mean, we're v- we're very good at trying to identify the things that will end your life in a binary fashion from a cardiorespiratory standpoint.

    14. PCPaul Conti1:46:58

        Yep.

    15. PAPeter Attia1:47:00

        We're not very good at identifying the things that are going to end your life emotionally. You know, I'm working on a book that's [chuckles] a day late, a dollar short. It'll be out there eventually. Uh, but in it, I talk about four types of death. The first one being the one that people think of, cardiorespiratory pulmonary death, like the, the, what I call death certificate death. But then I talk about these three other deaths. Cognitive death, so the, really the, the death of the ability of the brain, the decline of the ability of the brain, uh, with respect to, you know, processing speed, short-term memory, long-term memory, executive function. The, 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 two, three, and four, often precede one. In, 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 two, type three, and type four, but by far the one in which we are the most limited is this identification of type four. And part of it is, I think, shame. There's no question, right? Part of it is inadequacy of tools. So for example, when it comes to identifying type two or type three, 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, 'cause 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, you know, ethos that to be a really kickass hundred-year-old, I need to be a doubly kickass fifty-year-old. Um, and here are the steps that we're gonna 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 r-really, a person who's doing very well on the type one, type two, and type three, 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. Um, a lot of these people, of course, are not obviously suffering, right? 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. I mean, that, that's not a-

    16. PCPaul Conti1:50:13

        Right

    17. PAPeter Attia1:50:13

        ... huge cognitive leap for that person.

    18. PCPaul Conti1:50:14

        There are enough external markers that we can make that conclusion-

    19. PAPeter Attia1:50:17

        Right

    20. PCPaul Conti1:50:17

        ... with a high degree of surety.

    21. PAPeter Attia1:50:18

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

    22. PCPaul Conti1:50:59

        Well, see, the first thing I have to say is y- you've been kind enough to share with me some excerpts from the book, and, and when your book comes out, uh, it will be anything but a day late and a dollar short. And, and I think y- you're, 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, am I paying attention to my life in the way that I want to? And, and yes, that emotional aspect of it c- is the hardest to identify. As you said, there aren't serological markers for it, and, and often the, the truth of what may be going on is underneath the surface. And, and I would say that actually, you know, y- you already do the things there are to do, and, like, we could talk about how might it be formalized, right? But I, I think of, like, when you may refer someone to me, right? And, like, why is that, right? And I mean, tell me if this seems right, but, uh, but my thoughts-

    23. PAPeter Attia1:51:56

        Oh, yeah, I, I guess I would say this. I think we do a better job than most.

    24. PCPaul Conti1:51:59

        Mm-hmm. Mm-hmm.

    25. PAPeter Attia1:52:00

        Um, I guess what I'm really getting at is why can't we be doing better?

    26. PCPaul Conti1:52:05

        Right.

    27. PAPeter Attia1:52:05

        Why is it that there are some patients whom I suspect there's an issue, but as I broach it, there's complete denial?

    28. PCPaul Conti1:52:14

        Right.

    29. PAPeter Attia1:52:14

        Or there's other patients who on the surface will accept it, but then we can't get them to engage in it.

    30. PCPaul Conti1:52:22

        Right. Right. See, I, I think, right, the processes that you're going through, so again, my-- what, what do I think you're doing, right? And you can tell me if this makes sense, is I think that you're looking for people whose, whose actual behavioral choices are running countercurrent to what they're presenting for, right? And, you know, people are presenting to you t- 'cause they wanna be the healthiest they can be, right? So it's a little bit maybe the health systems are less like that, right? People are presenting just with problems, right?
16. 1:57:06 – 2:04:08

    How to reframe the conversation about mental health for a better future

    1. PAPeter Attia1:57:07

       Do you, do you think there will be a day when shame is out in the open, right? Because I mean, that's really what this comes down to, right? You have the stigma of trauma and then you have the, the, the, the vector of shame that works so effectively at keeping it in the dark.

    2. PCPaul Conti1:57:27

       Right.

    3. PAPeter Attia1:57:28

       And 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 the, that which needs to be exposed?

    4. PCPaul Conti1:57:41

       You know, I think a big part of that is an education process in our societies, right? That I think should start with-

    5. PAPeter Attia1:57:46

       And when you say education, what do you mean? Does this, 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, where, you know, should police be aware of this? I mean, like how, how broad a net do you cast?

    6. PCPaul Conti1:58:01

       Sure. 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, right? When you, when you talk about what goes on in people when they feel bad, right? When something makes them feel weird. What happens inside of you? What do you do with that feeling, right? Help the bully understand why he or she is bullying, right, when we're, when we're in first or second grade. Like let's, let's help that person understand and look at that person.

    7. PAPeter Attia1:58:24

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

    8. PCPaul Conti1:58:30

       Yeah, I think we, we do educate the professionals. Like we educate the doctors, we educate the teachers. I mean, there's so much that 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," right? But, but there's so many things that are done. You think about in medicine, like how many checklists, how much paperwork who's done that's utterly and completely non-contributory and everybody knows it, right? 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, right? And, and structuring the mental health resources so that there is a place to send someone, right? There's a place where we can have basic conversations about what's going on inside of them that then gates the care, right? There, 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, right? Where we start with early education, right, and we run that through educating professionals, right? Educating police, educating legal systems, right? There are mental health courts now. I mean, they're, 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, right? It can be different, but we've gotta look at it and we've gotta say, "Yeah, this is worth paying attention to," right? Is this what's w- in large part or in very significant part driving that we have now over one hundred thousand drug deaths in this country over the course of a year? Like why do we not feel a sense of urgency and, and want to look at our, the, the way that we provide help, right? And to say, "Do, do what we're doing, does what we're doing that drives doctors to burnout," right? 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," right? "And now they're just in a corner smoking cigarettes doing their own thing." Like 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?" Right? 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. Like why can't we look at this with a sense of urgency that says, "Oh, this isn't working," right? And then I think at the other end, people who, who other people look to and, and have a, a sense of respect for that will talk about their own trauma, right? A- as, you know, in some very small way like I'm trying to do, right, and you do, right? And Tim Ferriss has done, and even Stephanie Germanotta, so Lady Gaga, who was kind to write the forward for the book, that she talks about her humanness, right? That, 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, right, I'm not gonna pretend that I don't have any trauma, right? So, 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, right? Let alone if a person has a big public presence. So i- 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, is the m- the most important is on this grassroots level of, 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. You know, when that bully tells you that, you know, you're lousy because of what you look like or where you come from, right? Th- then what, what, what does that make you feel? And let's start looking at that reflexive sense of shame, right? Okay, can you stop and, and think about that, right? Like, you feel bad, right, when that happens. And what happens next? Well, you feel bad about yourself, right? Okay, let's put a full stop there, right? Like, that person's hurting you because he feels bad about himself, right? Like, like, and you don't. So then you start to put a barrier, right, between the reflexive shame, right, and the person feeling bad about themselves. Because how many people don't actually logically feel bad about themselves, right? But they, but they do actually feel bad about themselves, and it's the feeling that matters, not the facts, right? 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 ineffectiveness of the whole of our medical system, right? These are, these are big, all-encompassing aspects of our society, and we see, hey, these things are not going well, right? 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, uh, w- we don't know what to do about it, right? I mean, I'm pointing out solutions that I think are quite simple and well-grounded, and if we just follow them through, that it's resonating with people because I think it does resonate with common sense.

17. 2:04:08 – 2:10:06

    The growing impact of trauma on our society and the need for compassion

    1. PAPeter Attia2:04:08

       A moment ago, you alluded to a statistic that, uh, I think for many people is just almost impossible to fathom, which is the United States has just for the first time ever surpassed, uh, a one hundred thousand person mortality, uh, for a twelve-month period. So a hundred thousand people have overdosed in the United States-

    2. PCPaul Conti2:04:26

       Right

    3. PAPeter Attia2:04:26

       ... for the first time in twelve months. Do you see this as an epidemic of trauma and shame, or do you see this as really just a new, um, escape valve for it based on the availability of cheap and unfortunately highly potent opioids?

    4. PCPaul Conti2:04:46

       Yeah, 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, right? Are feeling like, "Look, I can't make my way in the world," right? "Whatever my chosen route of endeavor is, I can't make a living in that," right? "I can't support a family in that. I can't get ahead. I can't feel good about myself," right? And we see that in aspects of, like, almost the entire service industry, right, which has, which has changed to a, to a place where people can't have c- careers that then support their lives and support a family like was the case even twenty, twenty-something years ago, right? We see that even people who have good jobs, right, who feel like, "Okay, I finally got my way. If I work hard enough, I have a good job," that often that job 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 a person who doesn't have a job, right? And this desperation builds anger and frustration and resentment and all of these other symptoms, depression and panic, that spin off of it, right? And that makes it much more appealing to soothe in the short term. Like, that's a basic psychological fact of human beings, right? The more pain you're in in the short term, the more you're gonna choose a short-term solution without any consideration to the long term, right? I mean, if I'm absolutely desperately miserable and you've got something that can make me better right now, you know, I'm not gonna ask what that may do to me tomorrow, right? So we have developed a society that has become more and more and more hard-hearted, right, towards people's attempts to make their way in the world, right? And I s- think we see that with the response to the pandemic of, you know, "I'm gonna respond in the way that I want, and I don't really care about you," right? And, and, like, we've seen enough of that that, um, you know, I cringe at times at our, like, our inability to, to even have basic compassion for others, which of course isn't everyone, right? But, like, 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, right? That not that long ago, the way people often behave who have a public presence, right, would have led to censure by everyone. Th- they would say, "Hey, I, 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 gonna behave that way, talk that way, denigrate people that way." Like, we've moved far away from that, right? And we need to look at what are we doing in the world around us, right? How are we handling ourselves, and are we indirectly promoting the, this ethic of not really caring, right, that leads to the desperation that leads people to soothe with drugs, right? There's a very macabre... It's not even a, it's a, a joke. It's a, it's a, it's, it's a tragic atrocity, right, that people will say, "Oh, I'm, you know, I've-- Gosh, I have four people who are drug addicted in my practice I'm gonna see this afternoon," or, you know, or ten people, right? And, um, you know, it's not who it used to be, right? Because before it was people who'd sifted down to places in society where society's really turned their backs on them. Now it's people from all walks of life, right? And, and we see that socioeconomic demographic, educational demographic, geographic demographic, um, uh, racial, religious, or ethnic concepts. They, they're-- We've gone beyond that, right? Where, where now we're all menaced by this, right? 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. Right? [laughs] Like, we don't do anything about it, right? Which is, which is a tacit acceptance of it, right? If we don't look at what are we doing to people that drives them to desperation, right? Then we're not gonna make that statistic better. And how much is going on behind closed doors in the pandemic? How much violence behind closed doors, neglect behind closed doors, drug and alcohol abuse behind closed doors? Are we gonna look more at this, or are we gonna just pay lip service to looking at it, right, while we don't actually change anything, and then we'll be going, "Oh my gosh, isn't it so terrible?" It's three years from now, that number's 140,000, right? Well, if we don't really care now as a society, we just wanna marvel at the number and say how bad it is and do nothing, well, it's exactly where we're gonna go. That's why the number's been increasing, right? I mean, it's not rocket science to say that either. You just, 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 gotta do something different, right? Because this is staggering in the human misery that it speaks to. Not just 100,000 people lost. Not just, right?

    5. PAPeter Attia2:09:29

       That's right.

    6. PCPaul Conti2:09:30

       I mean, not just 100,000 people. What about all the people who love those 100,000 people? Like, what are we doing, right? Which is why when people would say, oh, like, sometimes I'll get approached like I'm in a... I'm doing something that's very niche, right? Like, I'm interested in trauma, right? [laughs] And it's like, no, this is not a niche, right? This, you get up to numbers like that, right, there's a cascade through the population, right? 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.

18. 2:10:06 – 2:17:29

    Society’s antiquated way of treating manifestations of trauma rather than root issues

    1. PAPeter Attia2:10:06

       Paul, a lot of times, um, 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.

    2. PCPaul Conti2:10:19

       Right.

    3. PAPeter Attia2:10:19

       So for example, um, addiction is a very common manifestation of trauma. And, um, the most obvious of those, or at least the one that probably gets most people's attention, would be substance addiction.

    4. PCPaul Conti2:10:31

       Right.

    5. PAPeter Attia2:10:31

       Alcohol or drugs. 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, um, perfectionism.

    6. PCPaul Conti2:10:50

       Right.

    7. PAPeter Attia2:10:50

       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, you know, AA, it's people with alcohol. If it's Al-Anon, it's family members of people with alcohol.

    8. PCPaul Conti2:11:13

       Right.

    9. PAPeter Attia2:11:13

       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 treated people, what if we bundled people together through the common lens of what the trauma was?

    10. PCPaul Conti2:11:36

        Yes.

    11. PAPeter Attia2:11:37

        Is that, 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 gonna have al- 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 would it, is it better the way we typically think of doing it?

    12. PCPaul Conti2:12:13

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

    13. PAPeter Attia2:12:35

        Right. Alcohol versus narcotics.

    14. PCPaul Conti2:12:37

        Right. And, and even at that level, right, let alone at the higher levels of this person is angry, this person is addicted to unhealthy foods, right? There's so many ways in which the, 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, right? And when we parse that out too much, then again, we're just trying to check boxes, and we're telling that person that, you know, what you have, this, this thing that is in a sense your burden to carry, is so much about you, right? The, well, I'm an alcoholic, and I'm a rageaholic, right? And, and there's just the very language we use about that is often so stigmatizing. That's the thing that's bad about you, right? Like, that's often the message. And again, not always, but that's often the message that it sends, as opposed to, like, none of us comes out of the womb, right, an alcoholic or a rageaholic or addicted to unhealthy foods, right? They have like, look what's happened to us along the way, right, that leads us to this place, and that's how we make a search for commonality, right? So, so we, we have a set of processes [swallows] that wanna further parse things out, right? We're so overly reductionist, right, that oftentimes we would see where the person who was an alcoholic would feel like, "Well, I don't wanna sit in a room with a, with a person who's addicted to cocaine." Like we don't, as if there's like nothing in common, right? As, as opposed to like, yeah, what's, what is in common? Because I knew the health histories of those people, right? Because I was the, the medical director of the clinic, right? And, and I would see, right, what, what is 80% commonality as a driving force amongst everybody is trauma. Right? And, and, and that's just here, if you step further back, you see that across the things that we, we get short-term relief from at the expense of our long-term health. And it-- the over-reductionism, I think, is a facet of wanting to just put things in little buckets and then gaining some satisfaction from that, right? But now, okay, now all it's, is, is in a bucket, and actually being in that much of a bucket, right? You know, like a marble that goes down, right, is like now you can't get to it, right? I mean, you can't get to what's real about it instead of like, you know, 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, right? I mean, that's often what, say, the bridge to recovery is doing. It's looking at like, "Hey, what is your trauma?" Right? Like, okay, now let's go forward from there, right? But, you know, that's because they're bringing a sophistication to it, and people who do that work just reflexively know that. They know that that, 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, you know, the aspects of our-- the science of it all catching up with it shows that, right? It's hijacking the same machinery in the brain, and, you know, 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, of how medical care is or how society views it, and we're so far beyond the science, right? And I will say this that, you know, I'll say this a fair amount, that if you're in a very, um, well-defined, uh, field of medicine, let's say cardiology or so, where like 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 like, you know, even just a couple years ago, like that's not okay, and one will identify that, right? And, and that's not okay, right? We'll have to change that, right? But in mental health, th-the practice within individual practitioners and the systems can be antiquated by a half a century, right? You know, or a couple thousand years in some cases. And like we don't come in and look at that, right? 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, right? Like it's somehow okay not to even talk about that, right? 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, 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, and how, how do we approach the helping process.

19. 2:17:29 – 2:22:50

    Potential role of psychedelics like psilocybin and MDMA in treating trauma

    1. PAPeter Attia2:17:29

       Changing gears for a second, Paul, the, the final thing I want to kind of ask you about is, um, the role of two substances in particular, psilocybin and MDMA, uh, 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 m-maybe more importantly, what is your optimism around these two molecules, um, both of which are really moving quite along a pathway-

    2. PCPaul Conti2:17:58

       Right

    3. PAPeter Attia2:17:58

       ... towards a clinical approval, a legalization, uh, for clinical use. Um, in the case of MDMA, it is for, in fact, PTSD.

    4. PCPaul Conti2:18:08

       Right.

    5. PAPeter Attia2:18:08

       Um, so kind of curious as to whether you see that as an amazing adjunct, uh, to what we're talking about or a slight adjunct or potentially less.

    6. PCPaul Conti2:18:22

       I see it as among the, the, the brightest sort of shining hopes for the future. And, and I think the, the data both from decades ago and the, the more recent data and the clinical experience in trials and the, the first-hand reports like 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, right? There's a way in which it provides so much greater potential for understanding and helping. And, and of course, you know, there, there are the, the, the processes 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. And, and a, a story I'll tell sometimes to try to capture that is, you know, where I grew up was close to the Delaware Raritan Canal. It, you know, in colonial times it ran between New York and Philadelphia, was part of a network and, and you know, I was always fascinated that, that like artifacts would be found. You know, somebody would be fishing and find a vase or something, right? And, and it was like a maze, right? These barges went up and down. I'm like, "What's in there?" Right? And, you know, people would find things and that was interesting. But then at some point in time they drained a whole section of it, right? And when the section was drained, my goodness what they found and what they saw, right? And, and it's the same kind of analogy that I think the helping powers of these substances are, are so strong that they can get us to places of really seeing what's going on inside of 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, you know, the CT scans can do for the, for the appendix to see that being able to do that with these helping modalities allows for understanding and is so, um, predisposes to and is permissive of change in ways that can let people reorient much, much faster. So I think there's a potential here for even a revolution within the field, but we have to safely and effectively incorporate those arrows into the quiver, right? And then we see, of course, what is often seen, which is many of the people or organizations wielding th- that have, you know, the magic amulet of like, "I am the source of the helping resources," don't like this, right? So we see some aspects of traditional psychiatric care that don't like this, and I think that's through a sense of threat, that, that I think the power of these resources make a lot of the tools that I wield, uh, seem maybe a little bit paltry in comparison, right? Now, that's not always the case, and if that is the case, wonderful, right? There are new, powerful tools coming to the fore. We need to approach it, those of us in Western medicine, through a lens of being respectful of what that is and wanting to understand the new modalities and, and approaching it from a lens that says, "Look, if I'm gonna help people and I'm gonna 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," right? In a way that does justice to the person coming in the door, right? If I'm coming in the door for help, I don't care what it is, I want the person who's gonna help me to have 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 i- incredible potential, and then we work towards integrating instead of splitting. And like we're, we're in a societal mode in this country that's very much splitting, whether it's sociological, it's political, um, a- and even medical, right? And I think, 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, right? And that by, by re-grounding 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.

20. 2:22:50 – 2:27:17

    Parting thoughts and resources for getting help

    1. PAPeter Attia2:22:50

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

    2. PCPaul Conti2:23:06

       Sure. So the title of the book is Trauma: 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, um, or, uh, the, the principles contained, uh, therein. And there's so many good helping resources around. NAMI, uh, is one of them, uh, that across the country has, um-

    3. PAPeter Attia2:23:30

       And, and sorry, what is that? NAMI? What's that?

    4. PCPaul Conti2:23:33

       Yeah, so N-A-M-I.

    5. PAPeter Attia2:23:34

       Okay, N-A-M-I.

    6. PCPaul Conti2:23:35

       So, so a great access to resources often on a local level, that th- there's so much help to be had, um, and some of that help we can access in our own homes, right? 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, and I think that's such a part of the message that I want to deliver, that it just isn't esoteric. And, and if we ground to what's really going on inside of us and paying attention to it and, and in a sense being brave enough to face it because we see hope in facing it, that w- we can begin a process of, of really helping ourselves and others. And, 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, that is about some of the, the, the real big picture of it and, and some of the more, um, you know, the more kind of rarefied medical aspects of it. And I think a, 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, um, really helps get the message out there because we all need the message.

    7. PAPeter Attia2:24:54

       Thank you, Paul.

    8. PCPaul Conti2:24:55

       You're welcome. Thank you.

    9. PAPeter Attia2:24:58

       Thank you for listening to this week's episode of The Drive. If you're interested in diving deeper into any topics we discuss, we've created a membership program that allows us to bring you more in-depth exclusive content without relying on paid ads. It's our goal to ensure members get back much more than the price of the subscription. Now, to that end, membership benefits include a bunch of things. One, totally kickass comprehensive podcast show notes that detail every topic, paper, person, thing we discuss on each episode. The word on the street is nobody's show notes rival these. Monthly AMA episodes or Ask Me Anything episodes, hearing these episodes completely. Access to our private podcast feed that allows you to hear everything without having to listen to spiels like this. The Qualies, which are a super short podcast that we release every Tuesday through Friday, highlighting the best questions, topics, and tactics discussed on previous episodes of The Drive. This is a great way to catch up on previous episodes without having to go back and necessarily listen to every one. Steep discounts on products that I believe in but for which I'm not getting paid to endorse, and a whole bunch of other benefits that we continue to trickle in as time goes on. If you want to learn more and access these member-only benefits, you can head over to peterattiamd.com/subscribe. You can find me on Twitter, Instagram, and Facebook, all with the ID Peter Attia MD. You can also leave us a review on Apple Podcasts or whatever podcast player you listen on. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take conflicts of interest very seriously. For all of my disclosures and the companies I invest in or advise, please visit peterattiamd.com/about where I keep an up-to-date and active list of such companies.

Episode duration: 2:27:21