Essentials: Therapy, Treating Trauma & Other Life Challenges | Dr. Paul Conti

Welcome to Huberman Lab Essentials, [music] where we revisit past episodes for the most potent and actionable science-based tools for mental health, physical health, and performance. I'm Andrew Huberman, and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. And now, for my discussion with Dr. Paul Conti. Paul, thank you so much for being here today. Well, thank you so much for having me. We could just start off very basic and just get everyone oriented. How should we define trauma? I think we have to look at trauma as not anything negative that happens to us, right? But something that overwhelms our coping skills, and then leaves us different as we move forward. So, it changes the way that our brains function, right? And then that change is evident in us as we move forward through life. We can see it in mood, anxiety, behavior, sleep, physical health. So, we So, we can identify it, and we can also see it in brain changes. If trauma rises to the level of changing the function functioning of our brains, then there is almost always a reflex of guilt and shame around the trauma that can lead us and often leads us to bury it, right? To avoid it, which is exactly the opposite of what needs to be done. We need to communicate and put words to what's going on inside of us. And And very often, a person knows, but they're not admitting that to themselves because they're afraid of it, right? They don't know what to do. But if you they start talking, then they'll they'll talk about the event or the situation. Could be something acute, or it could be something chronic that really has been harmful to them, right? And then they feel different afterwards. But that doesn't always happen. Sometimes it's a process of exploration, we you know, through dialogue, right? Whether whether it's written or whether it's spoken of of the person sort of exploring the changes inside of themselves. Maybe changes to their self-talk inside, changes to their thoughts about the world and whether they can navigate safely and readily in it. And, you know, it anchors as I talk about this, the example I'll use at times is the example of my own life where, you know, when I was much younger, in my early 20s, my younger brother took his life by suicide. And the you know, the response of guilt and shame and and hiding all of it inside of me was was it it sounds very dramatic, but but I wasn't acknowledging it, right? Cuz I didn't know what to do about it. And I felt guilty and I felt responsible and I felt ashamed. So, there was a an avoidance inside of me. So, so I didn't see that the change was in me, but I was taking care of myself poorly. Like there was enough going on that was unhealthy that I couldn't avoid the realization that like, "Hey, I'm different now and in these ways that are automatic." You know, my reflex to, "Can I make my way in the world? Can I have a good life? Can I be happy?" Well, my reflexes to that were all different and they were coming through the lens of heightened anxiety, heightened vigilance, a sense of guilt, a sense of shame, uh and a sense of non-belonging in the world. And and was ultimately good and helpful people around me, um and my own realization that hey, things are not going well, right? That led me to to then get some help and to be able to talk about it and realize like, gosh, like I need to face these things that are going on inside of me." Why do you think that when we experience trauma, these things that we called guilt and shame surface? Those emotions must exist in us for some reason. Mhm. Um but in this case, it seems like they they don't serve us well. So, why is it that we seem to be reflexively wired to feel guilty and feel ashamed when that's the exact opposite of what we need to do in the case of trauma? There's something adaptive that has happened in us through evolution that now becomes maladaptive in the way we live in the modern world, right? So, if you think of through most of human development, you know, people weren't living that long, right? The idea was to survive and reproduce. So, so traumatic things that happened to us, it would make sense for them to stay with us, right? So, you know, if you ate a new food and got really, really sick, it's like you better remember that, right? You know, if you see someone from the group of people, you know, a couple miles away, right? And one of those people attacks you, right? You better remember that. So, so the traumatic things that are sort of emblazoned in our brain are built to last, right? Things that are positive will generate some emotion inside of us, but things that are profoundly negative are much more likely to stay with us. And I think that that was adaptive, right? When all of that was about survival, right? And I think the same thing is true with with say shame. The limbic system, right? The the system often is called the emotion system, right? In our in our brains has actually, of course, varying function, right? And one aspect is affect, right? So, affect is aroused in us. It's created in us without our choice, right? So, if if we're walking down the road and someone jumps in front of us or pushes us, right? Then there's a response of fear, anger, right? Heart starts beating faster, you know, more blood to the muscles, you know, we we're getting ready to to fight, right? Or or run, right? And then we become aware of it. So, the aroused affect in us is also about survival and it has a very deep impact upon us. And shame is an aroused affect. So, somebody it it can be raised in us without our choice and it's very powerful, which if you think about that is an extremely strong deterrent. You know, imagine a a tribe or group of people, right? That are sheltered together and, you know, someone eats half the food at night or something, right? And like there's a very negative response, right? And that person feels shame because shame is so powerful to to control behavior, right? So, the way that trauma can change our brains and and stay with us in a way that says be more vigilant. Look at the world in a different way. Act more defensively, right? And and how that links to shame and to guilt. So, then guilt in in guilt becomes what gets called a feeling technically where we relate the aroused affect to ourselves, right? So, so shame, the aroused affect, and guilt, the next step, right? When we when the shame gets related to self, are such profound behavioral interventions and and deterrents that you can see, I think, how evolutionarily kind of all makes sense. If we're fighting for survival, you know, and we're an elder statesman if we make it to 20, this makes sense, but it doesn't make sense in a world where we live much longer, right? We navigate in all sorts of different ways, and there's so much coming at us that can be traumatizing. Our brains are built to change from trauma, but not in the way we experience trauma and not in the way that we live life in terms of the nature of living life and the duration of life in the modern world where these traumas that happen to us are often so bad for us because they they change how our brain is functioning and then our entire orientation to the world is different, and that could be for, you know, years and years. This idea that I've heard about before, I think it was a Freudian concept of a repetition compulsion. My understanding of this concept of the repetition compulsion is that we all want to solve our traumas, and it allows us to put ourselves into micro or again macro versions of that over and over again. We get to run the experiment again and again in an attempt to solve it. >> Right. is it that somebody who is in an abusive relationship goes on to have a second and third or fourth verbally or physically abusive relationship? >> We see that over and over. It's not necessarily in everyone, but boy, it is in a lot of people who have suffered trauma. On the surface of it, it's like it makes no sense. But then if we think, well, how does the brain How does our brains actually function, right? We're sort of trained, at least in Western society, I think, to think of ourselves as logical creatures, right? They're like, oh, we're logical and ultimately everything in us can just boil down to logic, which is completely not true. The limbic system, right, the emotion system, so to speak, inside of us always trumps logic, right? If you think about, does it ever make sense to run into a burning building? I mean, logic says no, right? But if someone you love is in the burning building, you people run right in, right? Because the limbic system says yes. So, when logic and emotion come head-to-head, emotion wins all the time. And the limbic system does not care about the clock or the calendar. So, how I would relate that to the repetition compulsion is is when people are repeating, what they're trying to do is to make things right, right? With the idea that if we can repeat the situation and make it right, it will fix everything, right? Which makes perfect sense if if we think, well, where is that concept coming from, right? It's coming from the emotional part of the brain that wants relief from suffering of the trauma and does not understand the clock or the calendar. So, if I can solve something now, I will also solve something in the past, right? Which is why I can't tell you how many times I've sat with someone and they're say we're starting to do therapy, right? And the person will say, "My last seven relationships have been abusive." And I'll say back something sometimes like, "Well, look, if if you tell me that you've had seven relationships that have been abusive in different ways, I'll agree with you. Like I only say that cuz that's never what someone says, right? But I think what you're going to tell me is you've kind of had the same relationship seven times. So they made the light bulb that goes off like I have not had seven different abusive relationships. I have had one that I've repeated seven times. And now we start getting to what's really going on and what needs to happen. That person needs to face what happened in that original abusive relationship. And it always comes down to the the same sort of concepts of of the person feeling terrified while the abuse was going on, feeling guilty, feeling ashamed, feeling like oh they brought it on themselves, they deserve it, they don't deserve anything better, right? Because the brain is trying to make sense of it, right? Or I I thought I could make that okay, but I couldn't, right? And then there's more guilt and more shame. And if that's stuck inside of someone, like that's bundled up inside of someone, you know, like a medical abscess inside a person, you know, a walled-off infection inside the body, this is the same concept in the brain, then of course the limbic system is going to want to fix that. And and it fixes it by trying to let's recreate that situation and make it right this time. I see that play out clinically over and over again. And why do things get better? Because we go to the trauma and we unlock it. It's not hidden inside where it can control things, right? We bring it to the surface and then we we can take away its power. The thought about the thing, the event, >> Mhm. or events plural, evokes this arousal, this internal state. It makes some people feel sleepy and exhausted, other people feel really anxious, other people feel angry. I mean, the arousal has all these different dimensions, as you know. It's clear we need to confront these things. And so how do we deal with arousal? How does one take what they feel inside about something shameful? What do you do with it in a moment? And does that have to be done in the presence of a skilled trained therapist? How do we deal with that internal arousal? We so often try and change the trauma of the past in order to control the future. And what what that really adds up to is the trauma of the past dominates our present. And and then we're not really living in the present, right? As we're trying to control the future. We're not going to do a great job of controlling our future if we're not really living in the present. And so the way to come at that again in the moment if you're saying, okay, in the moment if I need to fall asleep, right? I might say, okay, let me try and put that out of my mind. Let me try and thought redirect. So so there's short-term strategies that can let us be functional in the context of these changes. But the answer is to go look directly at that thing. Look at that trauma, explore that trauma, and sure that can be done with a professional and sometimes that's what makes sense. But not always, right? Sometimes it can be done by talking to another person, right? Writing it down, right? Look at what's going on inside of me that my mind is so stuck to this. Let's explore that. We're so afraid so often of looking at the trauma that has changed us that we'll look anywhere but at that. What ends up happening is when the person puts words to it, right? It could be in writing, could be talking to a trusted other or with a therapist, right? Things start to change. I mean, just the fact that you can talk about it. You can put words to it and other people don't recoil. That you know, that example of of the person who says, okay, I was abused by a coach when I was a child. And once they start talking about it, then they start talking about how you know, they were just innocent kids, right? And like they didn't know and like they really wanted to be on the team where this coach was treating them as special and and now they can look at themselves from the outside, right? They can look at themselves like they would look at someone else. You think it's so easy for us to see what's real and true if it's someone else, right? If you ask someone, you know, what do you think of someone who's 10, 11 years old who's abused and manipulated and abused by an adult? You say, "Oh my goodness, I feel compassion for that person, right?" But if it's us, right? Then, "Oh no, it's guilt and shame and we have to hide it away." And when the person starts looking at it, they can sort of see it from the outside and it starts to take the energy out of it. All the guilt and shame inside the person gets juxtaposed to like, "What really happened there?" And then they say, "Right, I was a terrified child. I didn't understand at all." And they can come to a place of compassion and now we are working against the guilt and shame. And if the person cries about it, then it's great, right? I mean, crying is one of the best coping mechanisms we have. It doesn't hurt us and it lets us grieve things. You know, we can't grieve if there's guilt and shame inside of us. It just blocks grief, right? We have to It has to be a clean slate in a sense in order to feel sadness. And then you see that it shifts from anxiety, anger, and frustration usually directed towards the self, guilt, and shame towards towards being able to process it and being able to bring to bear some compassion and being able to direct the negative emotion, so to speak, where they're warranted. And my goodness, the changes. It's remarkable how just getting it out there and having like 1 hour of talking like that, like like what we're talking about now, can can leave a person feeling immensely better. How do we do that in a way that isn't retraumatizing ourself in a major way or in a minor way? It starts with real introspection, you know? When things are bouncing around in our minds, often it's very non-productive, right? It's the same thing over and over again, and that's not helpful for us, right? So, if we're just thinking about it, and we're thinking in the same way we sort of in a sense always think about it, then all we're doing is reinforcing the trauma, right? But, if we can distance enough, then we can think in ways that allow us to have new thoughts, right? That that we weren't having. It's not just bouncing around in our minds. And if we speak or write, there even more mechanisms that come online in our brains. Right? That that are the sort of monitoring mechanisms. We think in a different way if we're using words, right? And we we are better able often to bring in that observing ego. Like, what's going on inside of me? So, so it can be very helpful to think. It can be helpful to talk to someone, to a trusted other, you know, friend, family, clergy, uh to write. I mean, these are things that can be done without expending any resources. And sometimes, if it's the symptoms are significant enough, like it we really do need to talk to somebody professional who can who can help us get to the root of the trauma. What are some of the characteristics that one should look for in looking for a therapist? If you look at what are the top 10 uh important factors to find in a therapist, just repeat rapport 10 times. It's trust. It's a back and forth. It's It's like, yeah, even though I'm doing I'm doing something difficult, I'm doing it with someone who's really helping me. It's someone who's in it with me, right? Someone who's really paying attention, wants me to be better. That's indispensable. I think that good therapists are not pigeonholed by a certain modality. They They may, you know, come at the world largely through a psychodynamic or a CBT or a DBT lens. There's lots of different, you know, ways to do therapy. But, when you really talk to those people, really good experienced therapists, it's all coming through the vehicle of the rapport, but they're practically shifting to what the person needs. If you have that, you've got a winning combination. So, people should perhaps try a few therapists and maybe have a session or two or three to see if they the rapport feels like it's taking root. >> Yeah, and I think that's why word of mouth is important, right? If someone you trust tells you, "Hey, this is a good person." That says a lot, right? It already makes the pretest probability, you know, it's quite high. How does one gauge how much therapy they they ought to be doing? And should it always be on the therapist to decide that? >> Yes, I think a lot of times it would be the therapist to say it looks more work, you know, more intensive work or can make a difference. But I think the person also needs to, you know, take ownership, right, of their own therapy and say, "If I don't feel helped enough, well, I have to think about that, right?" And and talk to the therapist about that cuz it may be it may be that therapist isn't a match. People can get into a rhythm of therapy where it's really not helping them, right? But they either feel sort of nihilistic about it, like, "Oh, I'm no better and I'm going to therapy." Do we really need to look at ourselves? And this is where the insurance systems often are very difficult cuz it's hard sometimes for a person to say, "Oh, I need more therapy." cuz that may not be possible. So there are sort of negative factors in the world around us, but ultimately I think the answer to the question comes down to observing ourselves and taking ownership of like what's going on in us and how we're feeling and and then feeling that that um commitment to self or to self-care to say, "I need to go change this." Now I'd like to talk a little bit about chemistry. Yes. Um drugs. How do you think about prescription drugs in the context of treating uh trauma and other and other conditions? And I think that we tend to overutilize medicines in this country because we have a health care system that that often it's so based on throughput that we want to polish the hood when there's a problem in the engine, right? So we overutilize medicines often as an end point, right? Oh, we're going to make that person's depression better with an antidepressant. Most of the time it's for that person's depression to really get better and stay they need to unravel what's driving the depression. So, the first kind of branch point can be what is the diagnosis? What is the level of severity, right? And I think that that's very, very important. In the vast majority of people who are helped by antidepressants, they're not they don't have clinically severe depression, right? Those medicines create more distress tolerance in us. If you can improve someone's distress tolerance and you can use medicines that that take away what clinically is rumination, right? Not a not the standard meaning of that word, but the clinical meaning of it where there are distress centers in our brain that are overactive and then we get stuck in these maladaptive negative pathways where we think about something over and over and over again with no real chance of solving it because that's not what's going on inside of us. So, medicines can help that, but we have to have some flexibility around their conception and you know, the modern medical system of like 15-minute visits, you know, to to a psychiatrist that are that are weeks apart. I mean, I don't understand how that goes well. We use I think approximately five times as much medicine, I think across the board as say the Dutch population. They have a health care system and a and a cultural system that to the best of my understanding is more rooted in taking responsibility for oneself. So, if a person comes in and cholesterol is high, right? The first order of business is hey, you got to take better care of yourself, right? Like this person really needs to lose some weight, exercise more, right? They don't they don't have just jumping to like, let me give you a medicine and and you know, and ship shift you through the health care system and out the other side of the door. So, I think medicines get overused in large part for systemic reasons um and also for some of these categorization reasons. Oh, that person meets some technical criteria for depression, we got to give them this medicine instead of really thinking wait, what's going on in this person? And I see this over and over again. I see someone who's on seven medicines and they're on seven medicines to treat seven different symptoms, and now they have side effects from all those seven medicines. Maybe two of them are to treat the side effects from the other five, right? And that's bad. I'd love to talk about psychedelics with the preface that we're talking about this in a in a legal clinical setting. What are your thoughts on these drugs for therapeutic potential, also potential hazards, et cetera? The data coming from the the labs and the academic centers is so powerfully positive. These are used in professional hands and with the right kind of guidance are extremely powerful tools, but used in the right way. What happens is we see less communication, less chatter in the outer parts of the brain, right? In the outer parts of the cortex. That's where language is, that's where vision is, that's where executive function is. So, planning and task task execution. So, so much of that is about making our way in the world around us. And I think when we take the neurotransmission out of those places, right? And we set it in a part of the brain and say the insular cortex, right? The parts of the brain that are sort of in the middle, right? Which which I think I believe is where our humaness really is. So, the psychedelics make there be less chatter, communication in these other parts of the brain, and then we become seated in the part of the brain that I I believe is most about our experience of true humaness. You know, it's why people can sort of see with clarity that oh, that trauma that like that thing is not my fault. Right? Like we feel a sense of compassion for ourselves. We relieve ourselves, release ourselves from guilt. And it's like, why is this so helpful to people? And I think it's because it can do what we are trying to get at in good therapy, but it can really catalyze that by just putting a person in that part of the brain that can see it for what it is without all that chatter in the cortex about I got to think it's your fault or you won't avoid it again and and that makes the repetition compulsion. How do I think ahead to the next thing that might happen and what else bad might happen? I mean we don't get anywhere doing that. These psychedelics, the medicinal value I believe is putting us in that part of the brain where a person can really find truth and that's why I think that that that it's come so far in these few years because I I I think that is very clinically evident and I think we're going to see more and more the value of that and how what the psychedelics do can become I believe a heuristic for understanding like wait, how are our brains really functioning and what are the parts that really matter to our experience of being human. It's those parts of the brain by the deep parts of the brain, the insular cortex and the and the areas around it that say light up when a person has an an experience of spiritual ecstasy or an experience of connection with another person, right? So we we kind of have these telltale markers that something is going on there that's very important and very special and then when they come in a sense back online with with in a normal cognitive way they realize like wow, now I'm applying all those mechanisms of trying to understand truth and to to that and what what I see is that it's true. And wow, it's true. Like I mean if we hear that all the time which tells me hey, something different is going on there and of course these are powerful tools also misused like very bad things can happen but you think about the clinical utility and what does it mean that so many people change for the healthier or even change their lives. I think we're likely to see that they are powerful anti-trauma mechanisms again used clinically in the right hands and and I think that we're also going to see that they're a heuristic for understanding our brain that goes against what I see as some of the reflexive hubris of well, the outer parts must be the best because that's what makes us human and other animals don't have it and we're better because we're human. I mean, this makes no sense, you know? I'd like to talk about MDMA. What sorts of states do you think MDMA is creating um that can uh explain why it's a useful therapeutic tool in some cases and and what sorts of cases those might be. This is very different than the psychedelics, right? Which are seating our consciousness in these deep centers of the brain, right? Whereas what MDMA is doing is sort of flooding with positive neurotransmitters, right? In certain parts of the brain. And I think what that creates is a greater permissiveness inside to entertain or approach different things. And when these systems are are flooded with these neurotransmitters, it's more permissive to sort of think about that, right? And to think about that without again, all the chatter of that's your fault or you're never going to get anywhere because of that or you know what that means or right? They they kind of go away and then we can think about it in a way that isn't through the lens of fear. And I think that's the power there is that there it's permissive of approaching something, contemplating something, um you know, a different a a novelty. We talk about a de novo approach. And I think that's also why the experience can vary because you could also see how if you're not thinking about something, right? So there's not a clinical guidance to it, you could you could be in a state where like, hey, I just feel good. But it But that's not necessarily problem-solving. So the clinical guidance says, hey, let's take that state and do something with it, right? Let's Now that you're in this state, let's hey, let's make hay while the sun is shining, right? You're in a state where we can look at things that are traumatic, right? We can approach them from a de novo perspective and we're coming to understand that they have immense potential to be helpful to us. But I think and hope that that only also increases our respect for the those modalities and what can come what negative can happen if we're if we're not respectful. I have a question about language. Um in your book you talk about how we need to be careful about the use of language around trauma. Maybe problem solving and problem describing in general. How should we think about language in parsing trauma and in your book you talk about um you give some cautionary notes about um talking about depression, trauma, and PTSD in terms that that might diminish their real um severity in some cases. And uh and then I was really struck by that. So maybe just touch on, you know, how should we talk about these things in a way that um doesn't diminish them for ourselves or for other people? And um at the same time honors the fact that there's a lot of trauma out there. Right. >> And um there's a lot of depression out there and and we need to talk about it. We just have to be very careful what we're saying and what we're communicating. And I think this doesn't mean because you know, there's a sort of phenomenon now where where people are trying to control language, I think too much. Like you can't say anything that someone else might find hurtful. You have to refer to people in ways they choose to be referred to even if those are ways that others don't understand or ways they themselves have decided or ways that might be psychologically or clinically unhelpful. So I think the over control of language is not good. But I think the specificity of language, of what are we trying to say, how are we defining it? Even the word trauma, right? We're talking about trauma. So we want to define what that means, right? It doesn't just mean like oh anything kind of negative, right? Because then that dilutes it down to meaning nothing, right? It also doesn't just mean you know, um injury in combat, right? Like we have to talk about what that is. So I think anchoring it to something that rises to the magnitude of overwhelming our coping skills and changing us. Like then at least I define it that way and I can communicate that to you and we can know understand what we're talking about. I'd like to talk about the concept of taking care of oneself. Mhm. We hear about this concept of taking care of oneself and and I think at a surface level um it can sound a little bit light, you know, oh take care take care take good care, you know, we um but to me it's a deep and powerful concept and I was very um happy to see it in your book and also to learn a lot of um >> of ideas about what that really looks like. Mhm. How should we think about taking care of oneself? I see here what I think is a very fascinating dichotomy, right? That in some ways like think about how complex our brains are, right? How complex are psychies, our unconscious minds, or there's so much complexity there. But on the other hand psychological concepts that are consistent with health are often very simple, right? We should but which I don't mean light, right? But but simple, straightforward, right? And and I think self-care is absolutely one of them. I mean how much is talked about how to take care of oneself that just skips over the basics that are necessary as a building block for all else. So it doesn't matter how many chefs or vacations or whatever a person has if the basics of self-care aren't squared away and it's not a light concept to say like look, are you sleeping enough, right? Are you eating well? Are you getting natural light? Are you interacting with people who are good to interact with, right? Are you accepting negative interactions in your life? Are you living in circumstances that make you feel okay or not? They're very, very basic premises but so often we're not looking at them at all, right? We're not looking at them at all because we tend to skip over them and we tend to skip over them either because again in some automatic way that sometimes is trauma driven or we're not going to look at that right and often not taking care of ourselves can have the punishment, distraction, right? There's so much that can come into that. Or our sense of power is is tied to not taking care of ourselves. I mean I'll give you an example is I I tend to for whatever reason do reasonably well with very poor self care. Right? And like that was very adaptive when I was in some medical training. Right? And I was like, okay, I can I can eat a lot today. I can not eat, right? I can sleep 2 hours. I can sleep 8, right? I mean overall that's not good and it hasn't been good for me as I've aged. But then I I realized something like I'm doing all these things to make myself healthier but like what? I ignore that? Right? And why am I ignoring that? That was a key question. Why am I ignoring it? Because somewhere inside of me is it was and still to some extent is this idea that my ability to be really functional, right? To generate success in the world around me is tied to my ability to do that. Right? That oh if I but if I stop doing that and now I'm like I'm eating and sleeping regularly then I'm going to lose some edge and so so you know even I think about this all the time but I I realized hey I'm also I'm not doing it inside, you know? And and I think it's really grounding to the basics that really help us of like what are the basics of what I'm doing and not doing in my life, diet, exercise, sleep, people, circumstances, leisure activities. I mean sunlight and I think immensely important and dramatically undervalued. I want to thank you for today's discussion. I found it to be incredibly informative and I know our listeners will also. I also want to thank you for the work you do. I've done a wide and deep search for people in these areas and there are so few who have the background in medical training and physiology in the psychoanalytic and psychiatric realm and also have um a grounding toward the future, you know, of what's coming and who can encapsulate so many different orientations and and bring them together into a coherent piece. And for your book, which is incredible, I will go on record saying I think this is the definitive book on trauma and I really encourage people to to read it and will continue to encourage people to read it. It has so many valuable takeaways and insights and tools there. So, on behalf of the listeners and myself, thank you so much for joining us today. You're very welcome and I I take that to heart and I'm very appreciative of being here. So, you're very welcome and thank you as well. Thank you.