back to indexDr. Paul Conti: Therapy, Treating Trauma & Other Life Challenges | Huberman Lab Podcast #75
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Welcome to the Huberman Lab Podcast,
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where we discuss science and science-based tools
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for everyday life.
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I'm Andrew Huberman,
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and I'm a professor of neurobiology and ophthalmology
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at Stanford School of Medicine.
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Today, my guest is Dr. Paul Conte.
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Dr. Conte is a psychiatrist who did his training
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at Stanford School of Medicine,
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and then went on to be chief resident
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at Harvard Medical School.
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He now runs the Pacific Premier Group,
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which is a collection of psychiatrists and therapists
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focusing on solving complex human problems,
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including trauma, addiction, personality,
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and psychiatric disorders.
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Today, we discuss trauma in detail
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and the therapeutic process in detail.
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For instance, we discuss what is trauma?
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How do you know if you have trauma?
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Dr. Conte shares with us, for instance,
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that not every experience that we think is traumatic
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is necessarily traumatic,
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and yet many people might have trauma
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without even realizing it.
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We also talk about the therapeutic process generally,
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for instance, how to pick a therapist,
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how to best approach and go through therapy,
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and how to evaluate whether or not therapy
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and your relationship to the therapist is working or not.
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We also talk about self-therapies
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because we acknowledge that not everyone has access to
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or can afford therapy.
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And we talk about drug therapies,
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for instance, antidepressants, antipsychotics.
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We talk about alcohol, cannabis, ketamine,
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and the psychedelics, including psilocybin, LSD,
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and we talk about the clinical use of MDMA
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and what the future of that looks like.
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The reason for bringing Dr. Conte onto this podcast
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is because I see him as the person who has the greatest
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and most holistic view of therapy, trauma,
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drug therapies, talk therapies,
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and how self-therapy and work with others can be integrated
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for both healing and growing from difficult circumstances.
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Dr. Conte is also the author of an exceptional book
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entitled, Trauma, The Invisible Epidemic,
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How Trauma Works and How We Can Heal From It.
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That book describes trauma and its many features
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and many tools, some of which we discuss
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on the podcast today.
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So whether or not you have trauma or not,
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by the end of today's episode,
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you will have a much deeper understanding
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about what trauma is.
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In fact, I'm confident that you will gain insight
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into whether or not you have trauma or not,
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whether or not people close to you have trauma or not,
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and the various paths to recovering
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and indeed growing from trauma that we can all take.
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As you will soon learn, Dr. Conte
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is an exceptional communicator and has a unique window
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into the trauma and therapeutic process
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that I know that all of us can benefit from.
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Before we begin, I'd like to emphasize that this podcast
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is separate from my teaching and research roles at Stanford.
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It is, however, part of my desire and effort
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to bring zero cost to consumer information about science
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and science-related tools to the general public.
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In keeping with that theme,
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I'd like to thank the sponsors of today's podcast.
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Our first sponsor is Roca.
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Roca makes eyeglasses and sunglasses
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that are of the absolute highest quality.
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The company was founded
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by two all-American swimmers from Stanford,
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and everything about Roca eyeglasses and sunglasses
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was designed with performance in mind.
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I spent a lifetime working on the visual system,
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and I can tell you that our visual system
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has to contend with a lot of different challenges.
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For instance, when you move from a shady area
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to a brightly lit area,
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your eyes and your brain have to adjust
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in order for you to be able to see clearly.
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Roca eyeglasses and sunglasses were designed
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with the biology of the visual system in mind,
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They're very seamless.
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You always see things with perfect clarity.
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The other terrific thing about Roca eyeglasses and sunglasses
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is they are extremely lightweight.
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Most of the time, I can't even remember
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that I'm wearing them.
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I wear readers at night,
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and I wear sunglasses sometimes in the daytime
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when it is very bright or I'm driving and so on.
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If you'd like to try Roca eyeglasses or sunglasses,
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go to roca.com, that's R-O-K-A.com,
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and enter the code Huberman
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to save 20% off on your first order.
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Again, that's R-O-K-A.com,
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and enter the code Huberman at checkout.
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Today's episode is also brought to us by Blinkist.
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I love reading physical books,
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literally physical hard copies of books,
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and I like listening to audio books.
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And now for my discussion with Dr. Paul Conte.
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Paul, thank you so much for being here today.
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Oh, thank you so much for having me.
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I've been looking forward to this
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and I've received a ton of questions about trauma,
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about therapy, about how to assess where one is
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in their own arc of problems
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and addressing familial issues
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and relationship issues and so forth.
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We could just start off very basic
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and just get everyone oriented.
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How should we define trauma?
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We all have hard experiences.
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Some of them we might ruminate on more than others,
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but what is trauma?
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To make the definition relevant,
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I think we have to look at trauma
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as not anything negative that happens to us, right,
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but something that overwhelms our coping skills
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and then leaves us different as we move forward.
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So it changes the way that our brains function, right,
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and then that change is evident in us
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as we move forward through life.
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So how do we know if we have trauma or not?
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I've heard before everyone has trauma.
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For instance, I've heard that if we are a child
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or when we are a child and we request love from a parent
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or attention from a parent,
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if they dismiss us, that that's a microtrauma.
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Is that overstating or unfair to the real issue of trauma?
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Do we all have trauma?
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What are microtraumas?
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What are macrotraumas?
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I think traumas that we might categorize
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as disappointments, right,
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or things that are negative but not deeply impactful,
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I think is not a helpful definition, right?
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I think the helpful definition is something
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that rises to the magnitude of really changing us
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and something that we can see both in how we behave,
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we can see it in mood, anxiety, behavior,
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sleep, physical health, so we can identify it
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and we can also see it in brain changes.
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So the fact that we become, say, more hypervigilant, right,
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more vigilant and then we can see
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that different parts of the brain are more active.
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So that definition, that definition captures how trauma,
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if it rises to a certain level,
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like what we would say trauma
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that makes a post-trauma syndrome, right,
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leaves us different, I think is the helpful definition
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of trauma because it's a clinical definition, right?
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It's changes in us as people and we can map those changes
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to identifiable shifts in our brain function.
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So how do we know if we've been changed by something?
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I mean, I can think back to childhood events
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where some kid on the playground or in the classroom
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said something I didn't like, something negative about me.
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I think most people can do that.
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We have a great memory for the kid that said something awful
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or the parent or teacher that said something awful
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that really felt like it hurt us
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or at least it stuck with us.
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So clearly one's brain, my brain in this example,
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has been changed by that event such that I remember it.
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But how do we know if something
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has actually changed the way that we are
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because of course we don't know how we would be otherwise?
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Right, that's difficult, right?
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It's doable, but it's difficult because the response.
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So if the trauma rises to the level of changing our brains,
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and I don't just mean like we have a new memory, right?
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So we can have memories of something that was negative.
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And in that sense, it changes the brain
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because now there's something we can call to mind,
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but it doesn't change the functioning of the brain.
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If trauma rises to the level of changing the functioning
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of our brains, then there's almost always a reflex
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of guilt and shame around the trauma that can lead us
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and often leads us to bury it, to avoid it,
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to feel that now there's something negative inside of me
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and it feels shameful or it feels
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like no one else would accept it, right?
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So what happens is people tend to avoid looking
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at the change in them, which is exactly the opposite
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of what needs to be done, right?
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The idea of in a viral pandemic, right?
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We wanna stay away from one another and isolate, right?
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But with the trauma epidemic,
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we need to communicate with other people.
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We need to communicate and put words
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to what's gone on inside of us.
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And very often a person knows, I mean,
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I've done so much clinical work over about 20 years
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that has focused on trauma.
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And a lot of the times the person knows, right?
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But they're not admitting it to themselves
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because they're afraid of it, right?
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They don't know what to do.
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But if they start talking,
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then they'll talk about the event or the situation.
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It could be something acute or it could be something chronic
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that really has been harmful to them, right?
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And then they feel different afterwards.
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Like, oh, after that, I started thinking differently,
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feeling differently, but that doesn't always happen.
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Sometimes it's a process of exploration through dialogue,
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right, whether it's written or whether it's spoken
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of the person sort of exploring the changes
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inside of themselves,
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maybe changes to their self-talk inside,
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changes to their thoughts about the world
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and whether they can navigate safely and readily in it.
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And it anchors, as I talk about this,
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the example I'll use at times
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is the example of my own life,
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where when I was much younger, in my early 20s,
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my younger brother took his life by suicide.
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And the response of guilt and shame
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and hiding all of it inside of me was,
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it's just very dramatic, but I wasn't acknowledging it,
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right, because I didn't know what to do about it.
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And I felt guilty and I felt responsible
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and I felt ashamed.
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So there was an avoidance inside of me.
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And then I wasn't saying to myself,
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hey, before this, you thought that you could be effective
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and you could make your way in the world.
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And if you were a good person and you worked hard,
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you could make a difference, right?
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And then afterwards I thought, I can't get anywhere.
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The world's against me.
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And I felt like, oh, my options are all gone.
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And I was like 24 years old, right?
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So I didn't see that the change was in me,
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but I was taking care of myself poorly.
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Like there was enough going on that was unhealthy
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that I couldn't avoid the realization that like,
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hey, I'm different now.
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And in these ways that are automatic,
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my reflex to, can I make my way in the world?
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Can I have a good life?
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My reflexes to that were all different.
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And they were coming through the lens of heightened anxiety,
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heightened vigilance, a sense of guilt, a sense of shame,
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and a sense of non-belonging in the world.
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And was ultimately good and helpful people around me
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and my own realization.
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And hey, things are not going well, right?
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That led me to then get some help
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and to be able to talk about it and realize like,
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oh my gosh, I need to face these things
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that are going on inside of me.
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From a psychoanalytic, psychological,
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and maybe even a neuroscience perspective, two questions.
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Why do you think that when we experience trauma,
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these things that we call guilt and shame surface,
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you know, everything you're telling me is that
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in the end, that's not adaptive.
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Why would we be built that way?
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So that's the first question.
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And then the second question is,
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you know, how should we conceptualize,
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you know, guilt and shame?
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You know, I think that we hear guilt, we hear shame.
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You know, how should we think about it?
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I mean, those emotions must exist in us for some reason.
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But in this case, it seems like they don't serve us well.
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So maybe in that order or in reverse order,
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you know, what is guilt really?
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What is shame really?
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And why is it that we seem to be reflexively wired
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to feel guilty and feel ashamed when that's the exact
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opposite of what we need to do in the case of trauma?
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No, I think these are great questions.
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And I mean, I don't think anyone knows the answers for sure.
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But my read of all of that is that there's something
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adaptive that has happened in us through evolution
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that now becomes maladaptive in the way we live
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in the modern world, right?
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So if you think of through most of human development,
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you know, people weren't living that long, right?
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And the idea was to survive and reproduce.
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So traumatic things that happened to us,
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it would make sense for them to stay with us, right?
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So, you know, if you ate a new food and got really,
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really sick, it's like, you better remember that, right?
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You know, if you see someone from the group of people,
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you know, a couple miles away, right?
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And one of those people attacks you, right?
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It's like, you better remember that.
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So the traumatic things that are sort of emblazoned
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in our brain are built to last, right?
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Things that are positive will generate some emotion
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inside of us, but things that are profoundly negative
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are much more likely to stay with us.
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And I think that that was adaptive, right?
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When all of that was about survival, right?
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And I think the same thing is true with, say, shame, right?
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So I think here it makes sense to talk a little bit,
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and actually I'm interested in your thoughts about this,
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right, that the limbic system, right,
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so the system often is called the emotion system, right,
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in our brains has actually, of course, varying function,
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right, and one aspect is affect, right?
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So affect is aroused in us, which I think the meaning
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then is it's created in us without our choice, right?
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So if we're walking down the road and someone jumps
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in front of us or pushes us, right,
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then there's a response of fear, anger, right?
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Heart starts beating faster, more blood to the muscles,
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we're getting ready to fight, right, or run, right?
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And then we become aware of it, right?
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So the aroused affect in us is also about survival,
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and it has a very deep impact upon us,
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and shame is an aroused affect.
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So it can be raised in us without our choice,
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and it's very powerful, which if you think about that,
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is an extremely strong deterrent, right?
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So if you had, you know, imagine a tribe or a group
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of people, right, that are sheltered together,
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and, you know, someone eats half the food at night
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or something, right?
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And like, there's a very negative response, right,
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and that person feels shame because shame is so powerful
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to control behavior, right?
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So the way that trauma can change our brains
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and stay with us in a way that says, be more vigilant,
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look at the world in a different way,
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act more defensively, right, and how that links
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to shame and to guilt, and then guilt becomes
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what gets called feeling, technically,
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where we relate the aroused affect to ourselves, right?
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So shame, the aroused affect, and guilt, the next step,
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right, when the shame gets related to self,
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are such profound behavioral interventions
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and deterrents, right, that you can see, I think,
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how evolutionarily kind of all makes sense.
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If we're fighting for survival, you know,
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and we're an elder statesman, if we make it to 20, right,
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this makes sense, but it doesn't make sense
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in a world where we live much longer, right,
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we navigate in all sorts of different ways,
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and there's so much coming at us that can be traumatizing.
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I mean, if you think about the news, right,
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I mean, how many times have I written a prescription
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for someone that says, no more news, right?
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You've actually written those prescriptions?
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Oh, yeah, yes, so glance at the news,
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like look at the news for news.
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Anything going on, I need to know, right,
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but what are people doing is they're looking at it
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and they're clicking and they're clicking,
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and there's a sense of being like enthralled
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in a very frightening way with the horrors
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that are in front of us, and it shows how, yes,
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trauma can come through acute things that happen to us.
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Trauma can come through chronic things,
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chronic denigration, whether it's based upon
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socioeconomic status, immigration status,
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race, religion, sexuality, gender identity,
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these chronic traumas, right, of being denigrated
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by the society around us or treated as less than
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can change the brain, but vicarious experiences
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can too, right, and we know this, it's not theoretical.
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We know that the changes in the brain can come
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from vicarious experiences too, which is why
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people who are glued to the news and then feeling like,
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oh my goodness, like what is happening?
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The mothers in the Ukraine who've lost babies in the war,
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like there are things that are so terrifying
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that if we spend so much time with that,
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it has a similar effect.
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So our brains are built to change from trauma,
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but not in the way we experience trauma
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and not in the way that we live life in terms of
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the nature of living life and the duration of life
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in the modern world where these traumas that happen to us
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are often so bad for us because they change
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how our brain is functioning and then our entire orientation
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to the world is different and that could be for
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years and years and decades and decades.
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It brings so much misery and suffering
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and at times it brings death.
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If you think about 100,000 overdose deaths
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in this country in a year, 100,000.
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Where is so much of that arising from?
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As a person who's treated addiction very intensively
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over many years, I think that, well, I feel sure
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that the majority of addiction that I see and treat
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arises ultimately, the roots of it are in trauma
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and are in trying to soothe something that's stuck inside
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that the person isn't letting outside
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because of the guilt and shame but it's running around
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in their head and it's tormented by it
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and now there's a pull for these drugs
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or sometimes medicines to soothe.
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So the opiates that were given after a minor surgery
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are like, okay, yeah, they help the pain
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from the minor surgery but what they're really helping
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is the pain inside, right?
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But that very quickly turns into addiction, danger, risk
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and we see that over and over again
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and not in a theoretical way.
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Like I see that in people who have been in my practice
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with addiction arising from trauma
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who have subsequently died.
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So it's sort of writ large in our existence
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in the modern world.
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Incredible to me that this is the way it works.
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What I mean by that is this idea
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that I've heard about before,
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I think it was a Freudian concept
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of a repetition compulsion.
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That this is what boggles my mind
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as I'm hearing this.
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Something happens to us or we observe something traumatic
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and instead of acknowledging that
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and trying to distance from it,
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there seems to be a reflex of shame and guilt in many cases
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and stuffing it away and then a repetition of behaviors
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to continue to try and to stuff it away.
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Like you're trying to pack, I don't know,
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recently I was packing a home
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and trying to get a sleeping bag back into the bag.
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It seems like it's always trying to mushroom out the top.
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This kind of thing, it takes a lot of ongoing effort.
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And at the same time that if this thing really exists,
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this repetition compulsion,
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people will return over and over again
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to the kinds of scenarios
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or at least the kinds of emotional states
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that look just like the trauma or resemble it in some way.
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So the question I have for you is,
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is the repetition compulsion a real thing?
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And why would we be wired that way?
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My understanding of this concept
link |
of the repetition compulsion
link |
is that we all want to solve our traumas
link |
and it allows us to put ourselves into micro
link |
or again, macro versions of that over and over again.
link |
We get to run the experiment again and again
link |
in an attempt to solve it.
link |
In the case of taking a drug that it's clear,
link |
certain drugs like opioids,
link |
it's clear how that would not allow us to deal with it.
link |
It's just masking the emotional state.
link |
But why is it, for instance, that somebody
link |
who experiences sexual trauma
link |
then places themselves into circumstances
link |
of more sexual trauma?
link |
Why is it that somebody who is in an abusive relationship
link |
goes on to have a second and third
link |
or fourth verbally or physically abusive relationship?
link |
Yeah, I mean, on the face of it,
link |
you just go, that makes no sense.
link |
And yet we see this over and over and over again.
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Yes, the first thing I would say
link |
about the validity of the repetition compulsion concept
link |
Like yes, we see that over and over.
link |
It's not necessarily in everyone,
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but boy, it is in a lot of people who have suffered trauma.
link |
And I think there's a very good reason.
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On the surface of it, it's like, it makes no sense.
link |
But then if we think, well,
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how does our brains actually function, right?
link |
We're sort of trained, at least in Western society,
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I think, to think of ourselves as logical creatures, right?
link |
That like, oh, we're logical
link |
and ultimately everything in us can just boil down to logic.
link |
And if we think about it enough,
link |
we're gonna understand how to make the right decisions,
link |
which is completely not true, right?
link |
That the limbic system, right?
link |
The emotion system, so to speak, inside of us
link |
always trumps logic, right?
link |
If you think about, does it ever make sense
link |
to run into a burning building?
link |
I mean, logic says no, right?
link |
But if someone you love is in the burning building,
link |
people run right in, right?
link |
Because the limbic system says yes.
link |
So when logic and emotion come head to head,
link |
emotion wins all the time.
link |
If emotion is powerful enough, it will always win.
link |
And so the limbic system is so important
link |
and the limbic system does not care
link |
about the clock or the calendar, right?
link |
And that's the answer.
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And I'll sort of say why to the repetition compulsion.
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So the limbic system doesn't know like,
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oh, it's now, it's today, it's May, it's 2022.
link |
It just doesn't care at all, right?
link |
So how I would relate that to the repetition compulsion
link |
is when people are repeating, what they're trying to do
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is to make things right, right?
link |
With the idea that if we can repeat the situation
link |
and make it right, it will fix everything, right?
link |
Which makes perfect sense if we think,
link |
well, where is that concept coming from, right?
link |
It's coming from the emotional part of the brain
link |
that wants relief from suffering of the trauma
link |
and does not understand the clock or the calendar.
link |
So if I can solve something now,
link |
I will also solve something in the past, right?
link |
Which is why I can't tell you how many times
link |
I've sat with someone and say,
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we're starting to do therapy, right?
link |
And the person will say, oh, gosh, like, I know,
link |
look, you just can't help me, right?
link |
I mean, my last seven relationships have been abusive,
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right, and I'll say back something sometimes like,
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well, look, if you tell me
link |
that you've had seven relationships
link |
that have been abusive in different ways,
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I'll agree with you.
link |
Like, I only say that
link |
because that's never what someone says, right?
link |
But I think what you're gonna tell me is
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you've kind of had the same relationship seven times.
link |
It's not seven things, it's one, right?
link |
And that's always, I don't think one time yet
link |
that has failed to be the case.
link |
And that's how, so if you think about it,
link |
that's how we start to elucidate what's going on.
link |
So the light bulb that goes off,
link |
like I have not had seven different abusive relationships.
link |
I have had one that I have repeated seven times.
link |
And now we start getting to what's really going on
link |
and what needs to happen.
link |
That person needs to face what happened
link |
in that original abusive relationship.
link |
And it always comes down to the same sort of concepts
link |
of the person feeling terrified
link |
while the abuse was going on,
link |
feeling guilty, feeling ashamed,
link |
feeling like, oh, they brought it on themselves,
link |
they deserve it, they don't deserve anything better, right?
link |
Because the brain is trying to make sense of it, right?
link |
Or I thought I could make that okay, but I couldn't, right?
link |
And then there's more guilt and more shame.
link |
And if that's stuck inside of someone,
link |
like that's bundled up inside of someone,
link |
like a medical abscess inside a person,
link |
a walled off infection inside the body,
link |
this is the same concept in the brain,
link |
then of course the limbic system is gonna wanna fix that
link |
and it fixes it by trying to let's recreate that situation
link |
and make it right this time.
link |
And that's, I mean, it's I think one of the best examples
link |
of how the right approach of how like, let's look at that,
link |
let's talk about that, right?
link |
What's really going on there?
link |
Wait, who should feel guilty and ashamed?
link |
Is it the person who was abused
link |
or the person who was abusing, right?
link |
And we can get at what's going on inside the person
link |
and that's what changes that.
link |
And then the eighth relationship can be entirely different
link |
than the first seven, right?
link |
And I see that all the time.
link |
I mean, this isn't esoteric or soft.
link |
Like I see that play out clinically over and over again
link |
and why do things get better?
link |
Because we go to the trauma and we unlock it.
link |
It's not hidden inside where it can control things, right?
link |
We bring it to the surface
link |
and then we can take away its power.
link |
I keep hearing in this narrative
link |
that so much of our reflexive response to trauma,
link |
both emotional and the repetition compulsion
link |
in terms of behaviors is about some very deep attempt
link |
to change the past.
link |
And in fact, in an offline conversation,
link |
I recall you saying something about this,
link |
that the number of behaviors and thoughts
link |
and avoidance of behaviors and avoidance of thoughts
link |
that human beings put in to try and change the past
link |
is remarkable and eerie and maladaptive, it sounds like.
link |
And that really stuck with me
link |
because I think we all want to feel like we're in control
link |
of our future and how we feel in the moment.
link |
And to some extent, it works for a brief while.
link |
There's this thing that happened
link |
and it just evokes some internal arousal.
link |
And then you have to know what to do with that arousal.
link |
And I think for many people, including myself,
link |
there's this fundamental question, okay,
link |
the thought about the thing, the event,
link |
or events, plural, evokes this arousal, this internal state,
link |
makes some people feel sleepy and exhausted.
link |
Other people feel really anxious.
link |
Other people feel angry.
link |
I mean, the arousal has all these different dimensions
link |
And then there's this question about what to do with it.
link |
And I'd love to hear maybe even just a top contour
link |
prescriptive of what does one do?
link |
I'll even just put myself in it.
link |
So I'm feeling upset.
link |
Should I feel like my options are healthy catharsis?
link |
I could tell the story, feel it.
link |
I could pack it down.
link |
We hear that it's bad to pack it down,
link |
but of course one has to be functional in life
link |
and deal with things.
link |
And we have responsibilities at work
link |
and relational responsibilities, et cetera.
link |
We need to sleep at night.
link |
So catharsis, healthy catharsis, packing it down
link |
at the end of the day,
link |
packing it down at the other extreme, telling the story.
link |
And yet I think a lot of people are afraid to tell the story
link |
because in that telling,
link |
there's perhaps a re-emergence of the arousal.
link |
The arousal can become greater.
link |
I mean, is that what people mean when they say things
link |
are going to get worse before they get better?
link |
I mean, so I guess the simple version
link |
of this long-winded question is it's clear
link |
we need to confront these things.
link |
We can't change the past by a reflexive response
link |
isn't going to do that efficiently.
link |
And so how do we deal with arousal?
link |
How does one take what they feel inside
link |
about something shameful?
link |
What do you do with it in a moment?
link |
And does that have to be done in the presence
link |
of a skilled trained therapist?
link |
Or as I'm driving to work in the morning
link |
and something comes up,
link |
I can't deal with this right now, comes to mind.
link |
Do I deal with it right then?
link |
I know this is a big multidimensional question,
link |
but I think it's the one that a lot of people grapple with.
link |
We want to deal with things.
link |
How do we deal with that internal arousal?
link |
We so often try and change the trauma of the past
link |
in order to control the future.
link |
And what that really adds up to is the trauma of the past
link |
dominates our present, right?
link |
And it doesn't have to be that way.
link |
And remember, we're talking about traumas
link |
that rise to the level of changing the brain.
link |
So as you're saying, that involves re-experience.
link |
It involves hyper-vigilance, increased arousal,
link |
changes in mood states, changes in anxiety,
link |
changes in sleep, changes in behavior.
link |
So these are all changes that, in a sense,
link |
push towards dominating our present, right?
link |
And then we're not really living in the present, right,
link |
as we're trying to control the future.
link |
We're not going to do a great job of controlling our future
link |
if we're not really living in the present, right?
link |
And so the way to come at that,
link |
again, in the moment, if we're saying,
link |
okay, at the moment, if I need to fall asleep, right,
link |
I might say, okay, let me try and put that out of my mind.
link |
Let me try and thought redirect.
link |
So there are short-term strategies
link |
that can let us be functional in the context of these changes.
link |
But the answer is to go look directly at that thing, right?
link |
Look at that trauma, explore that trauma.
link |
And sure, that can be done with a professional.
link |
And sometimes that's what makes sense.
link |
But not always, right?
link |
Sometimes it can be done by talking to another person,
link |
right, writing it down, right?
link |
Look at what's going on inside of me
link |
that my mind is so stuck to this.
link |
Let's explore that.
link |
Because it's almost as if we're so afraid so often
link |
of looking at the trauma that has changed us
link |
that we'll look anywhere but at that, right?
link |
So it's like it's hidden in a closet
link |
and we'll shine the light everywhere else,
link |
but we're not going to open that door.
link |
And that's where people will say the same
link |
as I've heard over and over.
link |
And I myself have thought this at times,
link |
like, oh, if I talk about that,
link |
I'm going to start crying and never stop, right?
link |
Or I'm going to just fall apart, right?
link |
Which is never what happens.
link |
No one ever starts crying and never stops, right?
link |
What ends up happening is when the person puts words to it,
link |
right, it could be in writing,
link |
it could be talking to a trusted other or with a therapist,
link |
right, things start to change.
link |
I mean, just the fact that you can talk about it,
link |
you can put words to it and other people don't recoil, right?
link |
I mean, how many times has someone said something
link |
for the first time, right?
link |
And when they're telling me about the trauma,
link |
there's such an anxious like,
link |
looking like as if I'm going to recoil from it, right?
link |
Meaning I'm going to recoil from them, right?
link |
And then there's a sense of surprise.
link |
If the person says, well, you know,
link |
I was abused by this coach when I was a kid, right?
link |
And there's not, okay, there's not a response of recoiling.
link |
You can see the change and people will say a lot like,
link |
wow, like, I can't believe like,
link |
you can like hear me say that and be okay with it, right?
link |
I mean, so you think about what's going on inside of them,
link |
like how, what a sense of shame, a sense of, you know,
link |
this is something awful about me for people to recoil from.
link |
And it's just not true, but here's where trauma is,
link |
it's insidious, right?
link |
And it's pervasive, right?
link |
Because if that convinces us to continually hide it away,
link |
then how do we explore it?
link |
Like that, you know, that example of the person who says,
link |
okay, I was abused by a coach when I was a child.
link |
I mean, I'm thinking of a couple of very real cases, right?
link |
People that I've taken care of.
link |
And once they start talking about it,
link |
then they start talking about how, you know,
link |
they were just innocent kids, right?
link |
And like, they didn't know.
link |
And like, they really wanted to be on the team
link |
where this coach was treating them as special.
link |
And now they can look at themselves from the outside, right?
link |
They can look at themselves like they would look
link |
at someone else, right?
link |
You think it's so easy for us to see what's real and true
link |
if it's someone else, right?
link |
If you ask someone, you know,
link |
what do you think of someone who's 10, 11 years old,
link |
who's abused and manipulated and abused by an adult?
link |
We say, oh my goodness,
link |
I feel compassion for that person, right?
link |
But if it's us, right?
link |
Then, oh no, it's guilt and shame
link |
and we have to hide it away.
link |
And when the person starts looking at it,
link |
they can sort of see it from the outside
link |
and it starts to take the energy out of it, right?
link |
Then, well, who should feel guilty about that?
link |
Who's done something wrong?
link |
And like, so now the conceptions come together,
link |
which is often a reflexive, that was my fault.
link |
I went back to it.
link |
I still stayed on the team.
link |
I went back next season, right?
link |
I let it happen again, right?
link |
All the guilt and shame inside the person gets juxtaposed
link |
to like, what really happened there?
link |
And then they say, right, I was a terrified child, right?
link |
I didn't understand at all.
link |
And they can come to a place of compassion.
link |
And now we are working against the guilt and shame.
link |
And if the person cries about it, that's great, right?
link |
I mean, crying is one of the best
link |
coping mechanisms we have.
link |
It doesn't hurt us and it lets us grieve things.
link |
We can't grieve if there's guilt and shame inside of us.
link |
It just blocks grief, right?
link |
We have to, it has to be a clean slate in a sense,
link |
in order to feel sadness.
link |
And then you see that it shifts from anxiety,
link |
anger and frustration, usually directed towards the self,
link |
guilt and shame, towards being able to process it
link |
and being able to bring to bear some compassion
link |
and being able to direct the negative emotion,
link |
so to speak, where they're warranted.
link |
And my goodness, the changes that happen.
link |
I mean, it's not like people are miraculously cured, right?
link |
But it's remarkable how just getting it out there
link |
and having like one hour of talking like that,
link |
like what we're talking about now can leave a person
link |
feeling immensely better.
link |
It seems to me in hearing this that there's this
link |
weird wiring that we have.
link |
Because what I'm hearing is when traumas happen to us
link |
or we observe them, what we need to do most
link |
is to confront those and the emotions around that directly.
link |
But instead our system defaults to guilt, shame,
link |
and trying to hide it.
link |
And this repetition compulsion of placing us back
link |
into things similar to those traumas,
link |
or even maybe even worse traumas in an attempt to resolve it.
link |
It's like the most maladaptive wiring diagram
link |
I could possibly think of.
link |
Emotional and presumably physiological wiring diagram.
link |
And this notion of trying to change the past
link |
by doing things now when the exact opposite
link |
is what's going to be beneficial,
link |
also seems like the whole system seems completely backwards.
link |
And I'm chuckling as I said, it's not because I'm amused,
link |
it's because I'm just baffled once again
link |
at how our wiring can often not serve us well.
link |
But it raises what I think is an important
link |
and interesting question, which is earlier you were talking
link |
about how people will seek out media
link |
that's really disturbing.
link |
They'll traumatize and re-traumatize themselves
link |
So that could be viewed as the repetition compulsion
link |
where the person will have the same relationship
link |
with seven different, same abusive relationship
link |
with seven different partners in sequence.
link |
And yet, as I say this, it also is becoming clear to me
link |
how this almost seems like a poor but desperate attempt
link |
to resolve it in some way.
link |
And so the fork in the road, if I understand correctly,
link |
is to really get to the seed incident,
link |
really get to the thing that started it all,
link |
as opposed to repeating it all.
link |
Does that have to be done in the presence of a therapist?
link |
Is there benefit to taking a walk
link |
and thinking about these things, breaking down
link |
and crying if that's what's necessary,
link |
or feeling angry if that's what comes up?
link |
The reason I ask it this way is because I worry,
link |
I'll just speak to my own experience,
link |
I worry that in reactivating or touching into the emotion
link |
around something, that that is itself a form
link |
of the repetition compulsion,
link |
because you're feeling it all over again.
link |
You're not seeking out something to evoke that feeling.
link |
So I realize this is a little bit of a circular argument
link |
or question, but I think it's one that I really struggle
link |
with in trying to parse all the outcome-based therapies
link |
that I hear about and the recommendations
link |
I mean, how should we conceptualize this?
link |
Something happens.
link |
It sounds like we need to deal with that thing directly.
link |
Do we need to do that with somebody else?
link |
Can we do that on our own?
link |
If we don't have resources and we have to do it on our own,
link |
can't hire someone, can't pay someone to work with us,
link |
how do we do that in a way that isn't retraumatizing
link |
ourself in a major way or in a minor way?
link |
How do we know where we are in that landscape?
link |
Again, those are, I think, great questions.
link |
And I think it starts with real introspection.
link |
When things are bouncing around in our minds,
link |
often it's very non-productive, right?
link |
It's the same thing over and over again.
link |
And that's not helpful for us, right?
link |
So there's an idea which sometimes gets called
link |
an observing ego, right?
link |
The ability to stop and look at what's going on
link |
inside of ourselves.
link |
And so if we're just thinking about it
link |
and we're thinking in the same way we sort of, in a sense,
link |
always think about it, then all we're doing
link |
is reinforcing the trauma, right?
link |
But if we can distance enough to be like,
link |
huh, I'm interested in what's going on inside of me, right?
link |
Like, I think of a certain person who really loves music.
link |
And then at some point in our therapy work,
link |
I learned, like, she was taking long drives,
link |
but the radio wasn't on.
link |
And I was like, well, what's going on, right?
link |
And I asked, and what was going on?
link |
And she was running over and over again in her head like,
link |
I'm a loser, I'm a loser, right?
link |
And she didn't want the music on because the music
link |
would drown out what she felt she had to say to herself,
link |
And it was that like, wow, that's interesting, right?
link |
And then her ability to observe that and to think,
link |
why am I doing that when it comes into her mind?
link |
Like, what is that trace to?
link |
When did I start doing that?
link |
Like I said, I'm saying it for a point of exaggeration.
link |
Like, nobody comes out of the womb
link |
programmed to think I'm a loser, right?
link |
So we don't think that when we're born, right?
link |
So where does that come from?
link |
Then we can think in ways that allow us to have new thoughts,
link |
right, that we weren't having.
link |
It's not just bouncing around in our minds.
link |
And if we speak or write, there are even more mechanisms
link |
that come online in our brains, right,
link |
that are then sort of monitoring mechanisms.
link |
We think in a different way if we're using words, right?
link |
And we are better able often to bring in that observing ego,
link |
like what's going on inside of me?
link |
So it can be very helpful to think.
link |
It can be helpful to talk to someone, to a trusted other,
link |
you know, friend, family, clergy, to write.
link |
I mean, these are things that can be done
link |
without expending any resources, right?
link |
And sometimes it can make really a big difference, right?
link |
There's a way, when did I start thinking that?
link |
And like interestingly in this case,
link |
okay, we did it in therapy,
link |
but it became very clear what that was rooted to, right?
link |
And then in the therapy, which was still relatively young,
link |
but we'd done several sessions
link |
and we weren't talking at all about what we needed to talk about, right?
link |
But that's what got us to what we needed to talk about.
link |
And when did that start?
link |
And now we're in that same place of exploring that
link |
and what was the reflex to it
link |
and the sense of guilt and sense of shame.
link |
And it's where all of that came from
link |
that just got boiled down to I'm a loser, right?
link |
Which this person didn't even have in their mind,
link |
like I didn't think about myself that way, right?
link |
And it's so interesting, right,
link |
that our memories don't in and of themselves have meaning.
link |
It's like they're flat or colorless, right?
link |
And they're colored in by the emotions that we attach to them, right?
link |
So the idea that certain memories now before the trauma
link |
were changed, right, by the trauma.
link |
So I tell the story sometimes of a person who like won an award
link |
when they were in high school that they thought was,
link |
oh my gosh, like it shows, like I can do it, right?
link |
And get out there that after trauma,
link |
they saw the award with a negative emotion attached to it
link |
that was like, oh, it was given to me and I didn't deserve it.
link |
And almost it was mocking,
link |
like there's going to be the greatest achievement of my life
link |
and I was 17 or so.
link |
And to have someone think like that's not
link |
how they felt about that at the time.
link |
It's the trauma that changed the self-talk,
link |
the internal state going forward.
link |
And talking about miraculous in a negative way,
link |
also changed that going backward, right?
link |
And when we can really look at like where did that come from
link |
and we can start unraveling it, it changes.
link |
So in those cases, you know, often it's helpful
link |
to have a good therapist.
link |
It's not always necessary and it certainly,
link |
it's not always possible, right?
link |
So we need other strategies.
link |
And some of those, I write about some of those in the book
link |
of how can we sort of get at trauma
link |
without those formalized mechanisms.
link |
And sometimes if the symptoms are significant enough,
link |
like we really do need to talk to somebody professional
link |
who can help us get to the root of the trauma.
link |
And there's so many times that's the answer
link |
to what's going on with people.
link |
You know, people I've seen have had five residential stays,
link |
I'm not exaggerating this, for mental health reasons,
link |
for substance reasons,
link |
and no one's ever taken a trauma history, right?
link |
And then when you take a trauma history, you say,
link |
well, that's obviously where this is all coming from, right?
link |
Like that's when the drug use started truly thereafter,
link |
the negative self-talk and the negative feelings
link |
that led to the drug use.
link |
Then you go after the trauma and you can change things,
link |
whereas trying to change things without looking,
link |
introspecting, talking about the trauma,
link |
I think of course was futile.
link |
Do you think that people can start to have negative fantasies?
link |
I mean, you mentioned this woman
link |
who would take these long drives to berate herself.
link |
I'm not familiar with that,
link |
but I'll give a little bit of personal disclosure here.
link |
I've felt several times in my life
link |
that I will start to create a narrative
link |
about something that truly hasn't happened,
link |
about something terrible that somebody is going to do
link |
that's going to upset me.
link |
And for the longest time, I would wonder,
link |
why am I doing this?
link |
And I have a couple ideas about why.
link |
One is that I was attempting to just avoid
link |
thinking about other things.
link |
It's just anger is such an attractive emotional force
link |
and it's an attractant.
link |
It's not attractive.
link |
And yet oftentimes anger is a great way
link |
to replace feeling something else,
link |
feeling sad or having to come up or to do work
link |
or to do something useful.
link |
So it has this kind of gravitational force to it.
link |
That was one idea.
link |
The other idea was in imagining kind of worst outcomes,
link |
then actually that relationship
link |
could actually seem a lot better in reality.
link |
It's almost like creating this negative contrast.
link |
It's like, oh, well then it's not that bad.
link |
And then the third possibility is I have no idea why,
link |
but it seemed like a reflex
link |
and I spent some time thinking about it.
link |
I can't say I've resolved it completely,
link |
but why would somebody have a narrative
link |
or a default narrative when driving or when walking of,
link |
I'm just going to spend some time
link |
and think about how terrible this thing is going to turn out
link |
or how someone's going to upset me or harm me
link |
or how terrible I am.
link |
It seems, again, like maladaptive thinking,
link |
maladaptive wiring,
link |
and yet I have to assume that it serves some purpose.
link |
I mean, I think there are three factors there
link |
and they're all bad.
link |
And I think you spoke to at least two of them, right?
link |
They, I think, speak so powerfully
link |
to how insidious trauma is
link |
and how these are real brain changes inside of us.
link |
So I would say the three factors, punishment,
link |
punishment, avoidance, and control, right?
link |
So the trauma inside of us that makes a guilt and shame
link |
so often, so often,
link |
leads to a desire to punish oneself, right?
link |
And the idea that,
link |
oh, that was my fault or I deserve that.
link |
Well, what do we do if something is someone's fault
link |
and someone now deserves punishment, right?
link |
I mean, we punish them, right?
link |
We send them to jail.
link |
We give them a fine, right?
link |
And so what we do is punish ourselves, right?
link |
And if we tell ourselves we're a loser
link |
or this awful thing is gonna happen, right?
link |
Then part of what we're doing is saying to ourselves,
link |
see, right, you deserve that.
link |
You're not gonna have anything better, right?
link |
It's a negative, it's a very negative way
link |
that the brain tries to make us, in a sense, do better
link |
by hurting us more for the things that we couldn't
link |
and shouldn't have been able to,
link |
weren't expected to control in the first place, right?
link |
The second is distraction.
link |
As you said, anger, that kind of fantasy
link |
can distract us from affect, feeling, and emotion
link |
that can be much more negative.
link |
You know, anger, it can be more gratifying
link |
certainly than guilt or shame,
link |
although guilt and shame can serve a punishment purpose.
link |
But if anger is directed also towards ourselves, right,
link |
then it can serve punishment too.
link |
So punishment, avoidance, and the sense of control
link |
that if you think ahead to something awful
link |
that you're imagining is going to happen,
link |
well, maybe that will let you avoid it, right?
link |
I mean, you can see the brain here,
link |
in a sense, really confused.
link |
I mean, part of the brain wants to punish,
link |
part of the brain doesn't want to think about it at all,
link |
and part of the brain wants to make it better.
link |
And then how all of that resolves
link |
if we're not aware that, hey, this is in the context
link |
of our brains being deeply impacted by trauma,
link |
so what's going on here is all maladaptive, right?
link |
Because these negative fantasies of the future,
link |
they may help us feel better about something in the present,
link |
but they don't help us make anything better, right?
link |
They don't help us make anything better.
link |
So this is the kind of the sequelae.
link |
This is where trauma and all this reflexive stuff
link |
that happens after trauma ultimately lead us.
link |
And you can see how we get lost,
link |
how I've seen over and over again in my own life,
link |
in the lives of other people, how, man,
link |
we get stuck in those situations.
link |
That's why I see people sometimes,
link |
this has been going on for 30 years, 40 years, right?
link |
And it's just been going on over and over and over again
link |
because there's no natural end to any of this, right?
link |
Unless we look at it in a different way,
link |
that we have knowledge and information like,
link |
whoa, this isn't the way it has to be.
link |
Let me bring a novel perspective to this.
link |
It doesn't change on its own.
link |
I'm struck by your statement that these thoughts
link |
or behaviors can make us feel better,
link |
but they don't actually make anything better.
link |
In that way, this mode of imagining terrible outcomes
link |
starts to immediately seem like taking opioids.
link |
You feel better in the moment,
link |
but it doesn't actually make anything better
link |
and it probably makes things worse.
link |
And just this question of how much worse
link |
and in what direction.
link |
And so I just want to just pause on that concept
link |
because I think that concept of makes us feel better,
link |
but doesn't make anything better.
link |
I think it answers an earlier question about
link |
this what seems to be a totally maladaptive wiring diagram.
link |
We need to confront the thing,
link |
but we don't want to go into the repetition and compulsion.
link |
So it's a knife edge there to navigate through trauma.
link |
Working with a very skilled clinician like yourself,
link |
I think is the ideal circumstance for people.
link |
And of course there are people who can't access support
link |
from somebody for whatever reason.
link |
You've talked about journaling as a useful tool.
link |
Could you, maybe you highlight some of the other things
link |
that people can do on their own.
link |
And then I'd also like to talk about
link |
what makes for a good therapist.
link |
What should people look for,
link |
for those that are seeking therapy,
link |
especially nowadays when a lot of therapy
link |
is being done remotely.
link |
But let's just start with the,
link |
let's just call them self-generated or zero cost
link |
Journaling being the first,
link |
and then what are some of the others?
link |
And what kind of structure
link |
would you recommend someone put around journaling?
link |
Carry a journal around all day
link |
and jot things down as they come up,
link |
or sit down and spend an hour
link |
writing in complete sentences, for instance.
link |
If I could add something to what you had just said
link |
before the question,
link |
I thought that we have these short-term coping mechanisms
link |
And in a way it makes sense, right?
link |
If we find ourselves in just terrible situations,
link |
then a short-term coping mechanism
link |
can get us through them, right?
link |
So our brains are built that way,
link |
and that's part of survival too, right?
link |
And whether now in the modern world,
link |
whether it's food, it's drugs, it's sex,
link |
it's alcohol, right?
link |
Or it's negative thoughts, right?
link |
This is short-term soothing.
link |
Even the negative thoughts and anger
link |
is short-term soothing at the expense of long-term change,
link |
And that's where, you know,
link |
addictive pathways can come into play.
link |
And that's where, again,
link |
how we're built evolutionarily for survival
link |
doesn't help us, you know,
link |
in the way humans have evolved.
link |
Like we haven't lived this way throughout, you know,
link |
99.9 something percent of human history, right?
link |
So we're not adapted to this.
link |
So I want to just make a point of saying that
link |
about the short-term soothing at the expense
link |
of long-term change, you know?
link |
And then the question you had asked about,
link |
say, journaling or what can we do
link |
that's outside of a professional,
link |
I think the hallmark of it has to be
link |
bringing new eyes to it, right?
link |
Like thinking about self with a curiosity
link |
instead of just a simple automaticity or repetition, right?
link |
Like, why am I thinking about this?
link |
When did this start?
link |
Why is this in me, right?
link |
It's that whether it's words or whether we're writing,
link |
that's so important.
link |
So I think for journaling, it depends on the person.
link |
I mean, we don't want somebody carrying around
link |
a journal all day if then there's a compulsion
link |
to I need to write about everything
link |
that's going on in my mind, right?
link |
Like that might be good to,
link |
okay, write a little bit at night, right?
link |
Or someone who might think, you know,
link |
sometimes this really comes into my mind in a strong way
link |
and it could be unpredictable, right?
link |
I want to have the journal with me.
link |
So, ah, that thing is back in my mind now.
link |
You know, let me write about it, right?
link |
Because then putting words to it
link |
and then being able to read those words, right?
link |
And when people read, even do a little bit of journaling
link |
and they read like, oh, I thought again
link |
about how I'm a terrible person who can't have a good life
link |
because I was in such a bad car accident
link |
or because that person attacked me
link |
or because when I was in school, I was bullied
link |
because I look different than everyone else, right?
link |
Or I acted different for everyone else.
link |
Wow, you know, to actually see that written out,
link |
it's, you know, it's a little bit of that,
link |
it's a little bit of that,
link |
like when you're saying it to someone
link |
as if it were someone else, right?
link |
Because now there's enough distance from it.
link |
Like I'm looking at the words I wrote, right?
link |
That we get some distance
link |
and we can start to integrate some of the,
link |
not just the compassion,
link |
but integrating compassion and logic, right?
link |
Of like, okay, I feel a sense of compassion.
link |
Oh, wait, what does this mean?
link |
What really happened here, right?
link |
And gosh, I did start thinking differently after that.
link |
I started, that's where this came from, right?
link |
That's why I'm saying this.
link |
It's those kinds of revelations that we can have
link |
through, again, the written or spoken word.
link |
And I think, again, that involves a trusted other
link |
or writing, right?
link |
And I think that those are ways we can do this
link |
where we bring some de novo perspective
link |
to something that often has been bouncing around inside of us.
link |
And it's amazing to me that, you know,
link |
I can see such intelligent and pathically attuned people
link |
who've had the same thing running over and over again
link |
in their mind for years.
link |
And it just points out that our brains
link |
don't automatically say, hey, wait a second.
link |
You know, I've been spinning wheels here
link |
for a long, long time.
link |
Like, was there another way to look at this?
link |
We need something from the outside,
link |
which can just be knowledge, right?
link |
Which is why I think what we're doing here
link |
or the reason I wrote the book that I wrote
link |
was like apprehending this like amazing surprise to me,
link |
right, which is like, wow, like some huge percentage
link |
of everything I'm treating is rooted in trauma
link |
and the opacity of trauma, right?
link |
Which is why we don't see that, oh, the depression,
link |
the panic attacks, the life change, the addiction,
link |
the, you know, the maladaptive choices,
link |
like, oh, this is all coming from trauma
link |
because it hides itself in that opacity.
link |
So we need a de novo perspective
link |
if we're doing it on our own.
link |
And we need that if we're doing it in therapy,
link |
which might link to like finding the right therapist,
link |
right, which is also part of your question.
link |
Yeah, I definitely want to know about how to assess
link |
and find the right therapist.
link |
Before we cover that, however, something came up
link |
in the course of your answer.
link |
I can immediately relate to this idea that, you know,
link |
certain behaviors are really maladaptive
link |
and our stuffing things down or avoiding the topic
link |
is problematic and bringing a curiosity
link |
and an introspection and almost a third personing
link |
of the experience that we've had in order to try
link |
and address it truly from a new perspective.
link |
It occurred to me as we were discussing this, however,
link |
that some people, and yes, maybe I'm talking a little bit
link |
about my own experience, we have a sense of our own identity
link |
and how people view us and our ability to be functional
link |
in the world in ways that we like.
link |
Effective at work or a good brother or a good mother
link |
or father or human being in the world.
link |
We have relationships.
link |
And I think that one thing that I have heard
link |
and maybe I've experienced is that sometimes
link |
those maladaptive thoughts or behaviors,
link |
the things that generate a kind of a repetition of anger
link |
or of arousal or activation or sadness that we have
link |
some internal process where we funnel that
link |
into a functionality in the world.
link |
So I'll give a more concrete example.
link |
So in thinking about things that have upset me in the past
link |
and in imagining bad outcomes in the future,
link |
there's a certain internal state of arousal
link |
And for many years, I was able to use that not to feel angry,
link |
but rather to work an extra three hours a day
link |
or to pack my schedule with work and social engagement
link |
so I could show up in a way that I hopefully
link |
was a very good brother to my sister, for instance.
link |
So in a way, it was a transformation of something negative
link |
inside of me into a functionality in the world
link |
that was actually very rewarding and beneficial.
link |
And yet in describing it, I can immediately see how
link |
it would be wonderful if I could source from something else.
link |
And yet I, you can imagine, and I can imagine
link |
how one would be reluctant, maybe even terrified
link |
of giving up that source.
link |
And I think in knowing some of the traumas of other people
link |
and their reluctance to work through those,
link |
obviously I'm not a therapist, I sense this over and over again
link |
that one's positive identity can often be linked
link |
to something difficult in their past.
link |
And so people are reluctant to give up this fuel.
link |
Because it's, in that sense, it's functional.
link |
The only thing that allowed me to kind of start to address this
link |
and why I'm still so curious about this,
link |
because I don't think I've worked through this process completely,
link |
again, a little more self-disclosure there,
link |
is that I was told that these words,
link |
just imagine how much better it would be
link |
if you could source from a different fuel,
link |
a fuel that felt better.
link |
Maybe it was on this sentence.
link |
It was maybe you could actually be much more effective.
link |
Maybe you could be 10 times the better brother.
link |
Maybe you could have 10 times more insider work capacity, et cetera.
link |
So it's on that hint of a promise that I,
link |
at least I was inspired to start looking into these things
link |
and reading about trauma in your book and elsewhere
link |
and start to think about this.
link |
So again, I realize this is a long-winded question
link |
and a somewhat complex idea,
link |
but I think, or I hope that people will be able to resonate with this idea
link |
that sometimes we want to stay attached to this short-term soothing,
link |
that the punishment, distraction, or control
link |
because it evokes this arousal and then we can apply that arousal.
link |
I think what you're describing maps, I think clinically,
link |
to what gets called sublimation.
link |
So there's something negative inside of us,
link |
but we sort of transfer that energy,
link |
we transfer that into something that is adaptive or that is positive.
link |
So the idea of anger, right?
link |
When I think of that thing and it makes anger in me,
link |
I channel that into harder work, right?
link |
Or I channel that into like,
link |
I'm going to go be nicer to my brother, something like that.
link |
And there's validity to that, right?
link |
But it can become like self-justifying.
link |
If a person thinks,
link |
well, look at what this is doing for me, right?
link |
I wouldn't work as hard without it, right?
link |
Now we start to become attached to the trauma.
link |
Whereas I think what you had said is absolutely true
link |
that just because we can sublimate some of the negative affect,
link |
feeling, emotion that comes from trauma into something productive
link |
doesn't mean that that's best, right?
link |
I mean, you know, we can get to our destination
link |
by taking a very circuitous route, right?
link |
We might waste an hour getting there, but we get there.
link |
That doesn't mean that that's best.
link |
And it also doesn't look at all the negative, right?
link |
In this example, the wasted fuel, the wasted time, right?
link |
We get somewhere, but we are not optimizing.
link |
And I have yet to see one person who has addressed the trauma
link |
and become less functional, right?
link |
It's always either they're just as functional,
link |
but they're happier, right?
link |
Or more functional because, as you said,
link |
like just because we may be able to sublimate,
link |
well, maybe what's going on will be 10 times better, right?
link |
If we weren't sublimating because the sublimation limits us, right?
link |
It limits our perspective to only what we can see and do
link |
through the lens of the trauma.
link |
And that is never better than the alternative.
link |
Thank you for that.
link |
Yeah, you're welcome.
link |
Let's discuss how one could or should go about
link |
finding a really good therapist.
link |
Typically, in my experience, this is done by word of mouth.
link |
You know, there's this person.
link |
You might want to work with them.
link |
They're really great.
link |
But what are some of the characteristics
link |
that one should look for?
link |
And should we take into account whether or not
link |
we are a person who, you know, for instance,
link |
I've heard this from listeners,
link |
although I'm definitely not talking about myself here
link |
in cloaking something.
link |
Some people will say, you know,
link |
I want to work with a somatic therapist
link |
because I've actually heard someone say,
link |
You know, I feel stuff in my body,
link |
so I want to work with someone who can really acknowledge that.
link |
Or someone else will say, you know,
link |
I want to work with somebody who has this orientation or that orientation
link |
or is open to my particular lifestyle
link |
or isn't going to tell me that I have to leave my relationship.
link |
You know, I feel like people already show up
link |
to the question of who to work with,
link |
with all these, you know, things internally,
link |
some of which are voiced and some of which aren't.
link |
So I'd love for you to talk about maybe
link |
some of the core features of a really good therapist
link |
and then how to look for a therapist
link |
and also how to think about oneself
link |
in looking for a therapist.
link |
Because of these kind of predispositions.
link |
Well, there's a lot of data about this over the years
link |
that if you look at what are the top 10 important factors
link |
to find in a therapist, just repeat rapport 10 times, right?
link |
I mean, that's the key.
link |
And if you think about that, it's pretty amazing, right?
link |
Because therapeutic modalities can be so different, right?
link |
And I think what that's telling us is,
link |
in a way, something very obvious, right?
link |
Like, what does rapport mean?
link |
Like, you know, somebody's paying attention, right?
link |
It's a back and forth.
link |
It's like, yeah, even I'm doing something difficult.
link |
I'm doing it with someone who's really helping me,
link |
someone who's in it with me, right?
link |
Someone who's really paying attention,
link |
wants me to be better.
link |
That's indispensable.
link |
I mean, it's just indispensable.
link |
And I write in the book,
link |
is someone, a therapist is not making eye contact
link |
or this is the way they do it, right?
link |
And you know, you gotta fit into the box
link |
of the way they do it.
link |
That is not going to be helpful.
link |
And then what I think about that is the different modalities.
link |
It doesn't actually tell us that,
link |
oh, the modality is irrelevant.
link |
I think that's not true.
link |
I think that good therapists are not pigeonholed
link |
by a certain modality.
link |
They may come at the world largely through a psychodynamic
link |
or a CBT or a DBT lens.
link |
There's lots of different ways to do therapy.
link |
But when you really talk to those people,
link |
really good, experienced therapists,
link |
it's all coming through the vehicle of the rapport,
link |
but they're practically shifting to what the person needs.
link |
You know, I don't understand the idea that like,
link |
oh, I just do this, right?
link |
And when people are pigeonholed that way,
link |
I don't think they help their patients very well, right?
link |
We have to be diverse enough to say,
link |
hey, I want all the arrows in the quiver, right?
link |
And even though there might be one that I favor
link |
and that's the lens I see things through,
link |
no, I can be versatile.
link |
I can adapt to what this person needs.
link |
And I think if you have that, you've got a winning combination.
link |
So people should perhaps try a few therapists
link |
and maybe have a session or two or three
link |
to see if the rapport feels like it's taking root.
link |
Do you have that right?
link |
And I think that's why word of mouth is important, right?
link |
If someone you trust tells you, hey, this is a good person,
link |
that says a lot, right?
link |
It already makes the pretest probability quite high.
link |
But yes, it's interesting to see when people have a therapist
link |
or they call their insurance and they're assigned a therapist,
link |
this thought that like, oh, that's the person I have to have now.
link |
And it's like, no, you should look at that like anyone.
link |
You know, you would be interviewing, right, for a job, right?
link |
But you got to bring again the right set of thoughts to that to be helped, right?
link |
Which is like, I want someone who has rapport with me.
link |
I don't want someone who's going to make it easy, right?
link |
Who's like, well, gosh, it's kind of pleasant
link |
because then that means they're not talking about the difficult things, right?
link |
So if one brings like, I know this isn't going to be easy.
link |
I got to talk about difficult things, right?
link |
Even if one doesn't recognize, oh, I got to talk about the trauma in me, right?
link |
But to go to therapy thinking, no, it's, I mean, sometimes it's enjoyable,
link |
but a lot of times, right, it's not, right?
link |
It can be excruciating.
link |
We can cry doing it.
link |
But to say, right, that that's how I'm going to be helped.
link |
And I want someone who's going to do that with me, you know,
link |
who's really looking at what's going on inside of me.
link |
How do we help me?
link |
And I can feel sort of the robustness of that.
link |
If one brings that approach and then looks at the therapist through that lens,
link |
you're very likely to then move on from someone who's not a good choice, right?
link |
And really stick with someone who is,
link |
even though that doesn't mean it's always like pleasant and enjoyable.
link |
I mean, it has to not be that sometimes.
link |
Maybe we could drill a little deeper into the mechanics of therapy.
link |
I put out a few questions to audience asking what they want to know about therapy.
link |
And it was amazing.
link |
I got hundreds, if not thousands of responses saying,
link |
how should I show up to therapy?
link |
So for instance, should people take a five-minute meditative drop-in before
link |
or should they just show up cold and let it emerge?
link |
During therapy, is it a good idea to take notes or to not take notes?
link |
And then post-therapy, how should clients, patients, as they're sometimes called,
link |
one or the other, I never know which, how should they process that information?
link |
Should they take some designated time afterwards and in an ideal world,
link |
take a 30-minute walk afterwards and think about the material
link |
or should they set it aside and come back to it?
link |
Of course, there are constraints, work and family, et cetera.
link |
But there's a lot of knowledge out there about how to best show up to a workout,
link |
warm up for five, 10 minutes, then do this, et cetera, and then the cool down.
link |
I mean, here we're talking about hard psychological work aimed at bettering oneself.
link |
So to my knowledge, I've not ever seen this information anywhere.
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It'd be very useful to hear your thoughts on this.
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Well, I'm not trying to duck the question, but I think it varies so much by person.
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So if you think about the first part of your question,
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I think was how to show up to therapy, right?
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And I think the answer would be whatever lets you be fully present when you're in therapy.
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Now, for some people, there's going to be, I show up early, you know, I sit, I calm myself,
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I meditate a little bit, I mean, that's how then they're present, right?
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For other people, you know, they just show up, walk into the room,
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they can stop another present, right?
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Because whatever works for that person so that they're really there,
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their thoughts, their energy is really in what's going on.
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And the same thing applies on the other end.
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You know, there are people who are really well served by, you know,
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going for a walk if they can or sitting quietly after therapy,
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kind of putting that in order, right?
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Otherwise they lose some of it, right?
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Or like some of the ahas, right?
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Or the, oh, that's an interesting thought that they really need to put it in order.
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Maybe that involves taking some notes during therapy, right?
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For other people, they need to do the exact opposite.
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They need to like leave, not think about that at all,
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and then they can reflect on it later and learn from it.
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So, you know, we're so different here.
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Human beings, there's such a diversity in us that I think there's no hard answer to that.
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But it's like being present when it's happening,
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then being able to sort of consolidate and retain what's been gained is most important.
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And I think we have to figure that out person by person.
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I mean, I try and do that in the work of like, what's serving this person best?
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And sometimes we, you know, sometimes it evolves and sometimes we talk about it,
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but it varies so much.
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If someone were thinking about embarking on therapy or more therapy to address trauma
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or just general issues of life, what is the frequency that you recommend?
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I could imagine two extreme models.
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One is, okay, I'm going to finally tackle this trauma.
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I'm going to do therapy three times a week, but for a shorter period of time, you know,
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six months, you know, over and out versus this open-ended model of once a week,
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typically for as long as it takes.
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I think that also varies.
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And I work with people in varied ways from someone who's doing well and like,
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we meet for a half hour every six months, right?
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To doing week-long hourly sessions, to spending three intense days with someone in a row, right?
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So I think as far as like kind of guiding principles, what I have found in my own life,
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because I value my own therapy tremendously, so I found in my own life and in my own clinical work
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that if it's less than once a week, then it's hard for us to retain really.
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You know, we spend a lot of time kind of catching up.
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Okay, what's happened?
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Let's get back to the place we were at before, right?
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Which is why I think if we're really going to get somewhere,
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we're not just trying to maintain something, right?
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Then I think once a week for an hour is really kind of the minimum, right?
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But more intensive work, it's like the more intense it is, it's not linear, right?
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It's an exponential gain.
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Like we do a lot of intensive work, right?
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Where someone will come and do 30 clinical hours with us over the course of a week.
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So five or six different clinicians, 30 clinical hours, and you know,
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we found that the benefits of doing that are immense.
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It's like a year's worth of therapy consolidated.
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And you take, well, 30 hours, let's say, you know, we go almost every week,
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maybe that's 45 or 50 hours, but 30 hours with that kind of intensity
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is worth probably 60 hours, you know, done in a different way.
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Because then it's in us in an active way, right?
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It's in the therapist in an active way, becomes very, very dynamic.
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So I think turning up the intensity if there's something
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that we really need to process absolutely makes sense.
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And I do that in my own life is something now it's like, whoa,
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something is really distressing me and it's linking into prior trauma.
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And I can see what's going on in me.
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Now I start to have ruminative thoughts, you know, with negativity.
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Like I got to go more, right?
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Because I got to do that processing so I can get to the place that I am,
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which is not that it's not that the trauma has no impact on me, right?
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It's that the impact is much less than it was before the therapy.
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And that I most often, more often than not, have an ability to see
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when it's now intruding into my thoughts.
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And it's taking me away from like what I really think and believe
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or being able to draw logic and emotion together and make good decisions.
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Turning up the intensity then absolutely makes sense.
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With this very deep intensive work of 30 hours in a week,
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what brings somebody to the type of work of that sort?
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Is it a suicide risk or a severe addiction situation?
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I mean, how does one gauge how much therapy they ought to be doing?
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And should it always be on the therapist to decide that frequency?
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What would bring someone to a situation of five therapists and 30 hours a week in one week?
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It's usually a person who is really distressed by something.
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You know, whether that's it's so negatively impacting their life or life.
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Or sometimes a person comes to a realization.
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I just can't take this anymore, right?
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I'm sick of this cyclical depression.
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I got to stop having panic attacks.
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Like I need help, right?
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I need help, right, but it's usually some, you know, crisis point with the idea of crisis
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and the meaning of, okay, something comes to a head and after it things are going to be different,
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Not a crisis and things are going to be negative afterwards,
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but a point where then that cognitive flexibility comes to the fore of like,
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wait, I need to do something different, right?
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So that's often what brings us, you know, sometimes it's other people pointing it out
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or somebody's had an intervention somewhere or yes,
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that person has been hospitalized after a suicide attempt or they've gone back to rehab again
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for the third or fourth time and their life is really in danger.
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Sometimes it's that and sometimes it's a person realizing,
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yeah, I just want to look at myself and understand myself better.
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You know, I know that what's going on in me isn't as good as it can be, right?
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So I think people can come to it for all sorts of different ways.
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And I think, yes, I think a lot of times it would be the therapist to say,
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it looks more work, you know, more intensive work or can make a difference.
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But I think the person also needs to, you know, take ownership of their own therapy
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and say, if I don't feel helped enough, well, I have to think about that, right?
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And talk to the therapist about that because maybe that therapist isn't a match, right?
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Or maybe you talk to the therapist and the therapist can change his or her approach, right?
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Or maybe you talk to the therapist and increase the frequency, right?
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But the idea is to be aware of it, right?
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And if one's needs aren't being met, to acknowledge that, right?
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Because people can get into a rhythm of therapy where it's really not helping them, right?
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But they either feel sort of nihilistic about it,
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like, oh, I'm no better and I'm going to therapy, right?
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Or sometimes there's a sense that, well, I'm in therapy,
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so I'm kind of checking that box of doing something for myself,
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but it's not really getting me anywhere.
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And then the part of the brain that's controlled by the guilt and shame and avoidance
link |
thinks that's a great idea, right?
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So again, this ability to observe ourselves and like, what's going on?
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Am I being helped in the way, do I feel helped, right?
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Am I in some ways even like happy that I'm not feeling helped
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because I don't have to face this thing I don't want to face, right?
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Or am I too afraid to say I need more help, right?
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Do we really need to look at ourselves?
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And this is where the insurance systems often are very difficult
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because it's hard sometimes for a person to say,
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oh, I need more therapy because that may not be possible, right?
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So there are sort of negative factors in the world around us,
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but ultimately I think the answer to the question comes down to observing ourselves
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and taking ownership of like what's going on in us and how we're feeling
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and then feeling that commitment to self or to self-care to say,
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I need to go change this.
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And for those that maybe don't have the means or insurance or access
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to do even one day a week therapy in the journaling model,
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could one perhaps take an entire day, as awful as it might seem,
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to do a lot of journaling and thinking and walking,
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you know, do a self-generated intensive.
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Do you think there's utility to that?
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I mean, there could be, but again, it depends by person
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because there could also be something negative about that.
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If it's, you know, someone who's not at the point, not ready for that, right?
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I mean, we don't come at, you know, we don't come directly at the trauma immediately.
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At least most of the time we don't do that, right?
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And we often don't explore it in depth.
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Like this idea that, oh, that person now has to go through every second of the trauma
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is actually not true.
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I mean, sometimes it is, but that's not the common situation, right?
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It's more often that person has to acknowledge like the example of like,
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I was sexually abused and if they acknowledge that into and say,
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okay, like, gosh, what has that done to me?
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That doesn't mean, well, let's parse out every moment of like,
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how that was and the terror of that, right?
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So that can lead people to a worse place, right?
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So I think the idea of biting off small pieces, so to speak,
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where a person is writing, right, or is talking,
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but I think if one is writing, it is good to communicate with another, right?
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Another trusted person.
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And if there's not someone in one's personal life, you know, they're clergy members.
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Even if one isn't affiliated with an organized religion,
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you could probably go places and get a clergy to want to help you, right?
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I mean, there are people out there who want to help other people.
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So they say, what if someone has no one?
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I mean, almost never do we have no one here, right?
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Because we could probably go find someone,
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but we need to take that in pieces.
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So there's some risk to trying to do the intensive thing, you know, on one's own.
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And that's where I would put it in, if a person's having suicidal thoughts
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or even thoughts of death, of not wanting to be alive,
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I don't deserve to be alive.
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I mean, these are warning signs for really getting help.
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So there are some signs that say, hey, don't try and do that on your own, right?
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Go try and find a resource.
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And it's, you know, things that get to that level of severity of,
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and often a person knows that.
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I mean, am I in a place where I know I'm not healthy
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and I'm having, you know, kind of scary thoughts?
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Then we need, that's a person who really shouldn't be doing that on their own.
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Great. Thank you for that.
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So we've been talking a lot about talking.
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And now I'd like to talk a little bit about chemistry, drugs.
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So maybe first we could talk prescription drugs.
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I mean, you're a psychiatrist, so you're approved to
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and presumably do prescribed medication where appropriate.
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And this is a vast landscape, of course.
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And I should just tell you, I get more questions about ADHD
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and the drugs related to ADHD and dopamine than any other topic.
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So there's ADHD, there's OCD, there's depression, there's antidepressants and so forth.
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Is there some way that we can, you know, wrap our arms around all of that
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as a way of wading into this drug question?
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And just address, you know, how does one decide when medication is useful?
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Because in the end, the dissection tool that the psychiatrist or therapist has is language.
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And at some point, one has to make an assessment about dopamine or serotonin
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or whether or not a given drug would help.
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And most therapies, I believe, don't involve putting someone in a brain scanner.
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And to my knowledge, there still is not a very good blood test to assess,
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oh, is this person's dopamine low or high?
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Correct me if I'm wrong.
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And ultimately that, and I know there are companies out there,
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so I'm not trying to undermine those companies.
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But if I happen to do that in this statement,
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if you take a blood test and find that your serotonin metabolites are low,
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my understanding is it's possible that you are too low in serotonin in the brain,
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but that's a very indirect window into what's really going on.
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So how do you think about prescription drugs in the context of treating trauma
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and other conditions?
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And then maybe we'll drill into some of the more specific conditions.
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I mean, I would first comment that there aren't tests for these things.
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And I think the tests for metabolites, I mean, things are so different.
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You know, by the time what we're talking about has been metabolized,
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you know, often to some very significant extent left the brain.
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Now it's in the peripheral blood that we really don't learn from that.
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And I think that we tend to overutilize medicines in this country
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because we have a healthcare system that often that's so based on throughput
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that we want to polish the hood when there's a problem in the engine, right?
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So we overutilize medicines often as an end point, right?
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Oh, we're going to make that person's depression better with an antidepressant.
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Well, I mean, maybe, right?
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But most of the time, for that person's depression to really get better and stay better,
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they need to unravel what's driving the depression, right?
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So the first step is, I think there are two steps to it, right?
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The first assessment step is, is there a diagnosis that the vast majority of the time,
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if not sometimes all the time, really warrants a medicine?
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So the bipolar disorder, OCD, ADD, right?
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These are diagnoses that we understand more about them and what's going on in the brain
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and how medicines can treat or stabilize them,
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which doesn't mean the medicine is necessarily, it's not a substitute for therapy, right?
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But sometimes the medicine and therapy can go hand in hand.
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So for OCD, for example, warrants therapy, but it almost, not always,
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but it almost always warrants medicine, too, so that you can ease the systems
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that are making the rigidity and the repetition in the brain.
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So the first kind of branch point can be, what is the diagnosis?
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What is the level of severity, right?
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And I think that's very, very important.
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Where I think it's a little more, maybe even interesting, is using medicines
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to help the person engage in the therapy as productively as possible.
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And here's where I think we're so limited by how we categorize medicines
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and this sort of pharmaceutical, insurance-driven medical system we have
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that I think throws us off in tremendous ways.
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So you think about how medicines are categorized, so antidepressants.
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And the vast majority of people who are helped by antidepressants,
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they don't have clinically severe depression, right?
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Those medicines create more distress tolerance in us, right?
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And if you think about how helpful that can be, if you're going to go,
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now you're going to do something difficult, where you're going to bring that trauma
link |
or the stressors to the surface and you're going to process
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and you're going to try and make life change.
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If we can make more distress tolerance in us, that can be so, so much better, right?
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And think about the category of medicines that are called antipsychotics,
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which really puts people off, right?
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But most of the prescriptions for antipsychotics are not for psychosis, right?
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And there are ways in which low dosing of some of those medicines
link |
can help intervene in negative pathways, right?
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In pathways that are about distress and sending out those tendrils of neurons
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that are about hypervigilance and avoidance in our brain.
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And we can often get at that.
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And if you can improve someone's distress tolerance
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and you can use medicines that take away what clinically is rumination, right?
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Not the standard meaning of that word, but the clinical meaning of it
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where there are distress centers in our brain that are overactive
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and then we get stuck in these maladaptive negative pathways
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where we think about something over and over and over again
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with no real chance of solving it because that's not what's going on inside of us.
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So medicines can help that, but we have to have some flexibility around their conception.
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And the modern medical system of 15-minute visits to a psychiatrist that are weeks apart,
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I mean, I don't understand how that goes well, right?
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In the vast majority of times, I think it doesn't go well
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because it's not enough time to do the therapy to even generate the understanding.
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So then medicines get thrown at the person.
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This is how we use, I think, approximately five times as much medicine,
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I think across the board as, say, the Dutch population, right?
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They think, why is five times more is a lot more medicine, right?
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And they have a healthcare system and a cultural system
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that to the best of my understanding is more rooted in taking responsibility for oneself, right?
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So if a person comes in and cholesterol is high, right?
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The first order of business is, hey, you can take better care of yourself, right?
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Like this person really needs to lose some weight, exercise more, right?
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They're not just jumping to like, let me give you a medicine
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and shift you through the healthcare system and out the other side of the door, right?
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And the same thing is true in mental health, you know?
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And I'm not trying to be critical to the psychiatrist or the nurse practitioners
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or people who are practicing in that way because oftentimes there is no choice, right?
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If they're working in a healthcare system that the standard is highly spaced,
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or spaced apart 15-minute visits, what alternative is there, right?
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But to look at, okay, I'm going to use medicines because I don't have another tool to bring to bear.
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So I think the healthcare system and its focus on throughput and its short-term,
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talk about, you know, we talk about short-term response, right?
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Short-term soothing at the expense of long-term health.
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And I think that is the metaphor that applies to our healthcare system, right?
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Where if we are going to try and treat a symptom in a short term,
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we're going to do it in a 15-minute visit,
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that we're going to do it in a way that maybe it soothes the symptom, maybe it doesn't.
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But it does not get at the problem.
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We need to invest more resources to get at the problem.
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And I think that's where a sort of protest, you know, if people as a society,
link |
we say, look, we don't like the way our healthcare is going.
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Like we need more focus on what the actual problems are.
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That yes, we would spend more money, you know, treating people and taking care of people
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because it's more human time.
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But ultimately less suffering, less death, right?
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And ultimately more productivity.
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I think as an economy, we would save so much money if we spend money
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on the human aspects of mental healthcare because people would be more functional.
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They're spending less time in the hospital, right?
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They're more productive when they're working.
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There's less entry into the criminal justice system.
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So I think medicines get overused in part for systemic reasons,
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in large part for systemic reasons and also for some of these categorization reasons.
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Oh, that person meets some technical criteria for depression.
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We've got to give them this medicine instead of really thinking, wait,
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what's going on in this person?
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And I see this over and over again.
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I see someone who's on seven medicines and they're on seven medicines
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to treat seven different symptoms.
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And now they have side effects from all those seven medicines.
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Maybe two of them are to treat the side effects from the other five, right?
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And that's bad, right?
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And if you really get at what's going on in them, now they're doing much better
link |
and maybe they're on two medicines, right?
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So I don't know if that's a helpful answer to that.
link |
It's a very helpful answer.
link |
I mean, I think at least in the spheres that I run these days,
link |
I hear a lot of negative statements about antidepressants.
link |
I think, you know, I'm old enough to remember the book,
link |
Listening to Prozac, and I remember when Prozac and things like it first started showing up
link |
and the excitement and then nowadays I hear more about the problems with all these drugs,
link |
you know, and maybe that's just because I have arms in the,
link |
both the scientific, but also in the kind of wellness community
link |
where people think a lot about behavioral change.
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Fortunately, I think that they do that.
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But of course, these drugs, as you mentioned, can have enormous utility as well.
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I'd like to just pick up on one theme that I haven't heard a lot about anywhere else,
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which is the short term versus the long term use of these drugs.
link |
Because I could imagine, you know, someone feeling like they're finally going to tackle
link |
something that's been inside them for a long time,
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either because they're really struggling or because they're just done with not working it through.
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And they decide to start a medication that would give them
link |
higher levels of distress tolerance for a short while.
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I mean, is there anything to say that someone couldn't take a properly prescribed medication
link |
for a week or for the first three months of the work and then know that they can come off it?
link |
Because I think that the black and white model of, okay,
link |
you're either going to start this drug and stay on it forever or be taking some drugs forever,
link |
or you're not going to take anything.
link |
I mean, that just seems to, life doesn't, does life have to work that way?
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Is there short term use that can be effective?
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Yeah, absolutely. Yes.
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In American medicine, we are so much better at starting medicines
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than we are at taking them away.
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And part of that, I think, is driven by such a strong presence of the pharmaceutical industry.
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And the pharmaceutical industry does a lot of very good things.
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But, you know, there's such thing as too much of a good thing.
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And then as a society, when something seems positive, this, I think, also is human nature.
link |
We can over invest in it.
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So you think about when Prozac and those kinds of medicines came out, they were safer medicines,
link |
they're billed as antidepressants, and the thought was, well, they're going to fix depression.
link |
And it's not how that works.
link |
So if we look at them as tools, right, then we can deploy them sometimes for the longer term,
link |
because sometimes that's necessary, but absolutely for the shorter term.
link |
I mean, absolutely.
link |
If we thought of Prozac and those kind of medicines, not as, oh, they're antidepressants.
link |
We thought, look, what they do is they seem to make there be more serotonin in certain circuits
link |
that are important for mood regulation, anxiety regulation, distress tolerance.
link |
So those medicines can really help somebody if they're very severely depressed and we
link |
want to sort of get them feeling better.
link |
They can also help someone if they could use more distress tolerance in a discrete period
link |
When we think about them that way, we think about them as tools that we could apply for
link |
short term or long term.
link |
We don't see them as fixes.
link |
And we don't see them as then substitutes for the human to human work that needs to be done.
link |
I mean, I've been sort of in my training at times in healthcare systems and I've seen
link |
in many other circumstances that look at medicines as answers.
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And this idea that, oh, that person is a, and a lot of times there'll be a number.
link |
And the number is the diagnosis and that number gets this medicine.
link |
And like, I'm not sure we could be more misguided than that.
link |
And that's what leads to adding medicines, adding medicines.
link |
Of course it's not working, you know, because no one's really paying attention to what's
link |
So add more medicines and then medicines for the medicines.
link |
And I mean, we know this is true.
link |
We know this is true, but we haven't had the wherewithal as a society to say, like with
link |
a lot of things in society to say, like, this isn't okay.
link |
I mean, we need more.
link |
Like give these people who are trying to help us, they need more latitude to help us.
link |
We need more human to human contact to get at what's really going on.
link |
And yes, that's an investment of time and energy and money in the short term.
link |
And sometimes that's money from the systems.
link |
But if we do that, my goodness, look at the payoff of that.
link |
What is your thought about anxiety and ADHD as a separate phenomenon in terms of medication?
link |
Again, ADHD is the thing that seems to come up most in questions.
link |
I can't tell you the number of, especially students, but also young working professionals
link |
and even people who are, you know, outside those categories who are interested in or
link |
taking Ritalin, Adderall, Modafinil, Armodafinil, or Vyvanse because they seem to struggle focusing
link |
Or, and I don't know, because I'm not one of those individuals, or because they seem
link |
to just like how well they can focus when they do take those compounds.
link |
And so my understanding is these compounds mainly increase dopaminergic transmission
link |
in the brain, also adrenaline, epinephrine in the brain.
link |
So they're more or less stimulants.
link |
They look a lot like, at least chemically, they look a lot like cocaine and amphetamine,
link |
although they're not quite cocaine and amphetamine.
link |
So should we be concerned about this?
link |
Is this a different sort of epidemic?
link |
Can these drugs be used to train the brain to focus and then people can withdraw from
link |
I mean, I think this is a huge topic and one that maybe warrants its own episode entirely.
link |
But as long as we're on the topic, what are your thoughts about medication for ADHD?
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I think medication for ADHD can be extremely effective.
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And the studies show us that, right?
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They show us that if there is ADD, then medication for ADD is very, very helpful.
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And that's true in youths.
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It seems to be true if adults have adult ADHD or ADD.
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Like we kind of know that's true, but all attention deficit is not attention deficit
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And there we go to the reflexive 15 minute visits, throw medicines at things, right?
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Attention deficit can come from many, many places.
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And one of them is anxiety, right?
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There's so many other reasons.
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Depression affects attention.
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Poor sleep affects attention.
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Poor diet can affect attention.
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Stress in life can affect attention.
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So, and certainly trauma and the thing, the problems that trauma spins off can affect
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So, you know, this is really the truth that while teaching once about medicines and pharmacology,
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I was frustrated about how the answer to everything was like, what medicine do we use?
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What medicine do we use?
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As opposed to like, this is just one piece of the puzzle.
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And I told an anecdote, which I think it was a clinical anecdote.
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Like, what do you think is going on?
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And I think that if I told that to, I don't know, middle school students or something,
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they would probably say, you just told the story of a person with a rock in their shoe,
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which is what I, the story that I was actually telling, right?
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But several people I was talking to, they're physicians, right?
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It's like, no, every time the person steps down, the rock hurts and they're not able
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to maintain attention, right?
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Like, that's what's going on.
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But we're so programmed to think about medicines and inappropriate use of ADD medicines.
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As you said, there's dopaminergic impact.
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There's epinephrine, norepinephrine impact.
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We're affecting what are called prefrontal alpha-2 receptors that like really need to
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be helped if there's real ADD.
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But if there isn't, that is not a good thing to do, which is why it is quite fascinating
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that when people have ADD, they tolerate generally stimulants very well without the other problems
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that can come of stimulants.
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And again, I don't know why that is, but we see that phenomenon.
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But when people are being treated for ADD and they don't have ADD, which sometimes they
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know they don't have ADD, but the stimulants make them function better, so they go to somebody
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and get the stimulants, that's not a good thing to do, right?
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Because stimulants, when they're not needed over time, they do affect our physical function.
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They affect our judgment, right?
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There are a lot of negative things that come from that.
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They can affect the vigilance inside of us.
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So yes, it's a valid diagnosis, but it gets made when it's not present very often, which
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we see with a lot of diagnoses that you can throw medicine at.
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We see the same thing with bipolar disorder.
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True bipolar disorder is extremely important to utilize medicines effectively, but how
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many people are diagnosed with bipolar disorder who absolutely don't have bipolar disorder?
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But it can be a catch-all diagnosis because there's, in a sense, something to do for it,
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And you can throw medicine at it, right?
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So I mean, what do we expect, right?
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If we have a healthcare system where you have 15-minute visits with your psychiatrist, of
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course we're going to throw medicines at everything.
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And then the training paradigms are going to look at it through that lens.
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And then very often, again, I give the example of seeing somebody on seven medicines.
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I mean, the first thought I have is, how many of those medicines are actually counterproductive?
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And a lot of the time, it's not like, oh, every now and then one is counterproductive.
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No, that's the case.
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That's the case a lot of the time.
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And again, I come back to, if we're not putting thought into it, what other result would we
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Thank you for that answer.
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I am very curious what constitutes negative effects of stimulants.
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So if somebody is taking Adderall or Ritalin in order to work longer hours or focus because
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they have attention deficit, but not necessarily ADHD.
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And again, I'm not recommending anyone do this.
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I've just heard the numbers that have come back, at least from surveys and discussions
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with colleagues at Stanford and elsewhere, other college campuses that upwards of 75%
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of college students use semi-regularly these drugs off, not by prescription, just to study
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I can imagine sleep issues because these are stimulants.
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What sorts of other issues can they create for people, problems they can create?
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I mean, I think a touchstone maybe that's running through our conversation is prioritizing
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the short-term benefit over solving a long-term problem, which we might say is a human tendency
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and we see it across the topics that we're discussing.
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So short-term use of stimulants, sure, people are more alert.
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They can stay awake more.
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They can study more intensely and longer.
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Okay, there's some short-term benefit of that.
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Over there, even there, there can be problems, right?
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But we can say, let's just say for sake of argument that in the short-term, there's
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something to be gained by doing that, right?
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But, oh my goodness, there's so much that is, there's so much risk to that, right?
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And how many times have I seen someone who they're doing that and they're just doing
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that to study, right?
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And now they're addicted to the amphetamines and their behavior changes and they don't
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Talk about shifting our brain towards a more defensive, you know, sort of suspicious outward
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look, you know, view of the world that we see a lot of that.
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So we see judgment impairment, we see heightened levels of anxiety, we see more impulsivity
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in decision-making, and sometimes we can get to the point of seeing frank psychosis.
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Now that's not common, but if I've seen young people who've done exactly what you're
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describing, right, they're using Adderall or they're using Ritalin to study, and then
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I see them when they're coming into the hospital, you know, screaming about how someone's
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trying to hurt them.
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Boy, it's the worst case scenario, but it shows like that's where that can go and how
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much is there between the, oh, I'm just using it to study, and that severe, you know, outcome
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that is actually quite negative for a person.
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It might change how they think about that friendship or that relationship, right?
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A lot negative happens when we change our brains without an ability to see like, what
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is it actually doing to us?
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So, which is part of my whole theme about trauma, right?
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It changes our brains and we don't know it, right?
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Well, the same can be, the same is often true of amphetamines used inappropriately.
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It shifts our brain and we don't realize that we're a little bit more impulsive in our
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decision-making, a little bit less trusting.
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These are significant negative things that if we don't know it, the person will just
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say, oh, I'm just using it to study.
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I'm using it to work more.
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That's not, you know, that's not without its high level of risk.
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What are your thoughts on cannabis?
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I've said it many times on this podcast before.
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I'll say again, I feel fortunate that I've never really been attracted to alcohol or
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drugs of any kind in so much so that if all the alcohol and all the marijuana and all
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the cocaine and amphetamine disappeared, I wouldn't notice any change in my life, right?
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And I feel lucky in that way because I know a lot of people feel an attraction to these
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things as almost a gravitational force from their first drink.
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They just feel, I once heard it described in this, I think it was an Augustin Burroughs
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book, Dry, where he was an alcoholic.
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He said that the first drink he had, it felt like this magic elixir that meshed with the
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physiology of his blood in the most seamless way.
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And as I was reading this, I thought, oh my goodness.
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First of all, that's the most foreign experience for me in terms of alcohol.
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And second, gosh, that must be terrible.
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And you can, but at the same time, you could really understand why someone would be drawn
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So cannabis nowadays is legal or decriminalized in many areas of the US.
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A lot of people seem to use the argument, it's better than drinking or they only do
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it for sleep or anxiety management.
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I'm not looking to demonize or support the cannabis.
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So what are your thoughts about cannabis for anxiety management, depression, and maybe
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even for ADHD for that matter?
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If I could make an alcohol comment, right?
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The number of times I've seen alcohol, like having been a good idea for coping with something,
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it approaches zero, right?
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Like the alcohol for coping is just never good.
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And there's an additional risk factor that there's certain genetic profiles where people
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respond strongly to alcohol.
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Like, as you're saying, it's not just, oh, there's a little bit of short-term relief
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of distress, but there's a sort of euphoric response.
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And those genetics, we don't understand them completely.
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They seem to be in Northern European populations, more prevalent as you had West in Northern
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So we understand that where risk factors are demographically, but we can't pinpoint that
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for any one person.
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And there's a tremendous risk of that when a person responds so strongly to alcohol or
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habituates coping to alcohol.
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Cannabis is a little bit of a different story.
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I mean, how I have seen that play out, and again, this isn't coming from any expertise
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around the neuropharmacology of it, like how is this really working in the brain, but it
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comes from an observation that what it seems to do is to narrow our attentional perspective,
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So it's why people will say, well, they want to use cannabis before watching a movie with
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friends or something, right?
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And I think, okay, I think why people are doing that is because a cognitive spectrum
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narrows, and then instead of worrying about that thing at work or that relationship issue,
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one can just be present, right?
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For it gates out other attentional intrusions, right?
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So in some ways, I mean, I've absolutely seen it be helpful to people.
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I mean, it's been legalized in Oregon, which is where I spend a lot of my time, and it's
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not where all of my practice is.
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But what I have seen is it is at times helpful, say, around sleep, right?
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Because a person can gate out other intrusive thoughts, and they can just relax and go to
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But there can be another side of that, too, that at higher levels of distress, right,
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stress, at higher levels of tension, what it can do is narrow the focus of cognition
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to the thing that is negative, right?
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So the idea that, oh, like, this is a treatment for, you know, depression, anxiety, trauma
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is not true, right?
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Can it be helpful under certain circumstances?
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Like, I think the answer to that is yeah.
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I mean, I know the answer to that is yes, because I've seen it play out clinically that
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But it can also be harmful, too.
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So there, again, like anything that has any power, power to influence our brains, we want
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to be thoughtful and careful about it.
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I mean, do I think that it's safer than alcohol?
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I mean, I think we so clearly see that.
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Does that mean it was just uniformly safe?
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So we want to be respectful of anything that can change how our brain is working, and I
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think that includes, certainly includes alcohol, and I think it certainly includes cannabis,
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I'd love to talk about psychedelics for two reasons.
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One, there seems to be a tremendous amount of interest in psychedelics as a therapeutic
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I know there's also recreational use, and I'll just preface all this by saying that
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my stance is we absolutely know for sure that these are controlled substances.
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They're illegal to possess, sell, or use in most of the country.
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There are a few areas where they are decriminalized.
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Um, they are decriminalized, um, and psychedelics is a broad category, of course, and we can
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touch on some of the different, um, different ones.
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But whereas five years or so, five years ago or so, I was truly afraid to say the word
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psychedelics in any kind of public venue.
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There are laboratories at Stanford working on ketamine, psilocybin, MDMA, mostly in animal
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There's terrific work going on at Johns Hopkins School of Medicine and Matthew Johnson's
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lab and others looking at the clinical applications, mainly of high-dose psilocybin and LSD.
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There's the MAPS trials with MDMA.
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So nowadays, it's safe for an academic like me to say the word psychedelics.
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And I'd love to approach this question of psychedelics from a place of true exploration
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and curiosity, but with the preface that, uh, we're talking about this in a legal
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Um, and the legality is something that's now in process.
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I don't think it's completed, but that's my understanding.
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But there are trials.
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There are, you can go to clinicaltrials.gov, uh, and put in MDMA and you'll see a bunch
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of clinical trials that are happening in the recruiting subjects.
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Um, so I think it's safe to have the conversation now and, uh, I'd love your thoughts about
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Maybe we could start with, um, psilocybin and LSD as a, as a broad category of drugs
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that at least my understanding is they touch on mainly the serotonin system, some specific
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receptor activation and modulation tend to change notions of space and time, adjust internal
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Maybe we would start there and then maybe venture into some of the other ones.
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So what are your thoughts on these drugs for therapeutic potential, also potential hazards,
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I think if we look at the true psychedelic, so psilocybin and LSD, because ketamine and
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MDMA, they're different categories of medicine.
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They're these sort of novel tools to bring to bear.
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But if we start with psilocybin, LSD, true psychedelics, I think why it is, why they
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have gained so much momentum over the last several years is because the data coming from
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the, the labs and the academic centers, um, is so powerfully positive.
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And as someone who's, I'm interested in anything that's potentially helpful, right?
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And I want to learn and understand that because a lot of things that are potentially helpful,
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you know, you go and look at the data and you see that that's not helpful or that's
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I think what we have seen with psychedelics is that they're so helpful, right?
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And, and the trials are bearing that out.
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And of course these are used in professional hands and with the right kind of guidance
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are extremely powerful tools, but used in the right way by, by someone who knows how
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to utilize them in the right set and setting can have an immense positive impact.
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And that's why I think that the thought is there across people and more and more people
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feel comfortable saying it and talking about it.
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I mean, we're in the state of Oregon now where, where the, the thought is we're moving
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towards legalization of psilocybin early in 2023 and it's part of the new data, right?
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And how it meshes with the older data, right?
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How it meshes with data from the sixties and seventies that showed such a strong, powerful
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impact of these medicines.
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And I have a whole set of thoughts about what's happening there and they're just, they're
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conjectures, right?
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But, but my read of, you know, as best I can try and understand the neuroscience and, and
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and the clinical applicability and the changes is, you know, what happens is we see less
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communication, less chatter in the outer parts of the brain, right?
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The outer parts of the cortex.
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And I think that as human beings, we sort of glorify the parts of the brain that only
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I mean, certainly in my growing up, right?
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I mean, what did I learn?
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Even if you think about like learning about the brain in high school, right?
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I learned that like, wow, we're great as humans because we have language and other animals
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don't and we can use tools and like, aren't we so great because we have this part of the
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brain that other animals don't and it lets us function, right?
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There's some truth to that, right?
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That, that, that we can do things others can't do, but we, we get lost often in the outer
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parts of the cortex, which I think are about survival, right?
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So we come back to the things you and I talked about early on of like, why are these trauma
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mechanisms in us, right?
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So much of what's going on in our brains is about survival.
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And I think living, so to speak, in the cortex, right?
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In the outer part of the brain is consistent with a focus on survival.
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So if you think that's where language is, that's where vision is, that's where executive
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function is, so planning and task execution.
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So, so much of that is about making our way in the world around us.
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So we tend to glorify that and think, well, that's in a sense where our existence is,
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And I believe that is not true, right?
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And again, can I say that for sure?
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Of course not, right?
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But my read of 20 years of doing clinical work and thinking about all sorts of medicines
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and, and thinking about the psychedelics with a, in a lot of depth, I think that what they
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do is they take us out of the cortex, right, because that's where we run into these problems.
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That's where we bounce things over and over again, that the distress centers deep in our
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brain, in the brainstem, kind of ally with the outer parts of the cortex.
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And they say, right, we're in distress, we want to stay alive.
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You know, often, a lot of us have had trauma that makes these changes in the brain.
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And then we're thinking all the time, like, what would I do if, if there were war?
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What would I do if there's civil war, if someone bombs us?
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What will I do if the, if the economy collapses, right?
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What will I do if somebody gets sick?
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We're thinking all this future projection that is all coming from a place of fear, right?
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It's all coming from a desire to think about things and control the future with this part
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of the brain that is so uniquely human, right?
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And I think when we take the neurotransmission out of those places, right, and we set it
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in a part of the brain and say the insular cortex, right, the parts of the brain that
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are sort of in the middle, right, which, which I think, I believe is where our humanness
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So the psychedelics make there be less chatter, communication, these other parts of the brain,
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and then we become seated in the part of the brain that I believe is most about our experience
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of true humanness, which is why when you read about, you know, people who have experiences,
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and I've heard about them, people talk to me about this, right?
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They've, they've utilized it, they talk with me.
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So whether it's someone telling me their story or it's coming from research data, you know,
link |
it's why people can sort of see with clarity that, oh, that trauma, like, that thing is
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not my fault, right?
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Like, we feel a sense of compassion for ourselves, we relieve ourselves, release ourselves from
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guilt, and it's like, why is this so helpful to people?
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And I think it's because it can do what we are trying to get at in good therapy, but
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it can really catalyze that by just putting a person in that part of the brain that can
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see it for what it is without all that chatter in the cortex about how you got to think it's
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your fault or you won't avoid it again, and that makes the repetition compulsion.
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How do I think ahead to the next thing that might happen and what else bad might happen?
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I mean, we don't get anywhere doing that.
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And I think where we get somewhere is when we seat ourselves deeper in the brain, which
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I think we do if we're, like, doing really good therapy and we're, you know, we're in
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the deep parts of the brain, but these psychedelics, the medicinal value, I believe, is putting
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us in that part of the brain where a person can really find truth.
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And that's why I think that it's come so far in these few years because I think that is
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very clinically evident, and I think we're going to see more and more the value of that
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and how what the psychedelics do can become, I believe, a heuristic for understanding,
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like, wait, how are our brains really functioning and what are the parts that really matter
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to our experience of being human?
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It's those parts of the brain, right, the deep parts of the brain, the insular cortex
link |
and the areas around it that, say, light up when a person has an experience of spiritual
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ecstasy or an experience of connection with another person, right?
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We kind of have these telltale markers that something is going on there that's very important
link |
and very special, and I think we're more attracted to the outer parts of the brain in part because
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they're easier to study, right?
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I mean, as you know better than I do, we started studying the brain through lesion studies,
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right, because it's easier to see if a person got hurt in this part of the brain or had
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a stroke in that part of the brain, what changes?
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So we look at the cortex because, one, it's easier to study, and we tend to glorify it,
link |
and I think that has been misguided, and I think that we're learning about how that's
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been misguided through the study of these novel modalities from Western perspectives,
link |
which, of course, they've been used for a long, long time in other cultures, but novel
link |
from our perspective.
link |
Yeah, I'm fascinated by this idea that in these middle brain structures is where our
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humanity lies, and as you said, I also wonder whether or not other animals experience life
link |
more from that orientation with less chatter.
link |
We can only guess, but, you know, the dog lover and being in the presence of animals
link |
that seem to just be present in what's happening in their immediate environment, not too much
link |
Right, I mean, what you're talking about is sentience is important, and sentience is extremely
link |
important, right, and if we're going to overvalue, say, language, then I think we undervalue
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sentience, right, which is why I think we tend to undervalue animals, right, and their
link |
suffering, because, well, they're not saying anything about it, right, and, you know, they're
link |
not writing about it, so, okay, it's easy to ignore, and we think about, again, the
link |
hubris of that, right, though, because we can think and talk and write, like, we must
link |
be feeling more than species that don't do that.
link |
I mean, I think that is so true, and that we're going to understand more about sentience
link |
and other species and how, you know, that's at the core of existence, and my hope would
link |
be that we value more humans and animals, right, through the evolution of that understanding.
link |
The hallucinations that accompany psychedelics like LSD and psilocybin have such an attractive
link |
force to them as a concept and as an experience, and so I think most often when people hear
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hallucinogens, they think, and psychedelics, they think about hallucinating, right, makes
link |
sense why they would, but what's so interesting to me is nothing in your answer about psychedelics,
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psilocybin, and LSD focused on hallucinations per se.
link |
It was more about feeling states, accessing a feeling state or a relation to an event
link |
or to a person or to oneself.
link |
Maybe even I caught hints of maybe even empathy for oneself for the first time.
link |
None of that had to do with seeing sounds or hearing colors and, you know, these kind
link |
of cliche statements about hallucinations.
link |
So I am aware of laboratories, one at University of California Davis in particular, but a few
link |
others that are trying to generate chemical variants of psychedelics that lack the hallucinogenic
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properties but maintain these other properties as therapeutic tools, and as I say that, I
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realize that people in the psychedelic community are probably thinking, oh, that's horrible.
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That's the dismantling of the core thing, but the simple question is, do you think the
link |
hallucinations are valuable for anything?
link |
And I think we're really getting into the philosophical, right, the ontological, right.
link |
There's this sort of trying to understand being, right, and I don't claim to know the
link |
I think that at times it seems like the hallucinations have a metaphorical or a symbolic way of being
link |
helpful, right, because people will come to understand things that they hold dear and
link |
true after the experience, right, that often, not always, come through the lens of the hallucinations.
link |
So are the hallucinations necessary?
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Are those hallucinations sometimes important, sometimes not?
link |
I mean, I think we don't understand that, and I think we want to be respectful of sort
link |
of mystery of that.
link |
But what I think is fascinating is you think about like substance abuse and what that means
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is, well, one aspect of that is that a person has experiences, thoughts, conceptions of
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self in the world with the substance that without the substance they know are wrong,
link |
People talk about, you know, liquid courage, right, and okay, I feel better about myself
link |
and I feel courageous because I've had a couple of drinks.
link |
Now after that, I feel like normal about myself, and that was false, right.
link |
And we see that like that's part of what substance intoxication means, right.
link |
But what we see with the psychedelic medicines is something that's incredibly different,
link |
right, that people are having experiences that are so de-linked from our normal experience
link |
And then when they come in a sense back online with in a normal cognitive way, they realize
link |
like, wow, now I'm applying all those mechanisms of trying to understand truth and to that.
link |
And what I see is that it's true.
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And wow, it's true.
link |
Like, I mean, we have that all the time, which tells me, hey, something different is going
link |
And of course, these are powerful tools, so misused, like very bad things can happen.
link |
But you think about the clinical utility and what does it mean that so many people change
link |
for the healthier or even change their lives after an experience because it so resonates
link |
as like, oh, now I understand something that's true.
link |
And it's not something bizarre.
link |
It's like I wasn't responsible for being raped that time.
link |
Or, you know, I'm not less than even though my sexuality or my gender identity is different
link |
from some silly binary concept, right?
link |
Like people kind of often get it and they feel differently about themselves and guilt
link |
and shame are impacted.
link |
So I think we're likely to see that they are powerful anti-trauma mechanisms, again, used
link |
clinically in the right hands.
link |
And I think that we're also going to see that they're heuristic for understanding our brain
link |
that goes against what I see as some of the reflexive hubris of, well, the outer parts
link |
must be the best because that's what makes us human and other animals don't have it.
link |
And we're better because we're human.
link |
It means it makes no sense.
link |
I'd like to talk about MDMA.
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And I'll preface this by saying I was a participant.
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Actually, technically, I'm still a participant in a clinical trial.
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So I have experience of doing it twice.
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The trial involves three separate dosings of this.
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One is I was reluctant to do it outside of a clinical trial, mostly because I was aware
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there can be some cardiac effects.
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And I liked the idea there'd be a clinician on hand.
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And I'll just say that I found the experiences to be profound, beneficial, and very different
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from one session to the next.
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The first one felt a whole collection of ideas and relational things came up that felt very
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powerful and transformative.
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And I do think that I learned there.
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I exported a number of things.
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My particular experience isn't relevant here.
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But the second time I expected it to be the same way.
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And it was very mellow and relaxing and was deeply tied to notions of acceptance.
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So there weren't all these revelations and wow, new insights.
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It was very much about grounding into a kind of a calmer state.
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So I have the personal experience of benefiting from these in ways that I think still benefit
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me and was very struck by the power of MDMA.
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And my very crude understanding of the pharmacology and the state that is being under MDMA is
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that it encourages or increases dopaminergic transmission, but also serotonergic transmission,
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which is to my knowledge, a kind of a rare state for the brain to be in that typically
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it's more of a seesaw of dopaminergic drive towards external goals or more serotonergic
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drive towards more placidity or comfort with what one already has.
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And so with both those systems amplified, the only way I can describe it subjectively
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is that everything sort of funneled back in and it was almost like a pursuit of inner
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landscape and I can only imagine what it would be like in the context of doing this with
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somebody else also taking MDMA.
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I have no idea what that's like.
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That's my report of the experience.
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I know that the experience can vary.
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What are your thoughts about the chemistry and what sorts of states do you think MDMA
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is creating that can explain why it's a useful therapeutic tool in some cases and what sorts
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of cases those might be?
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To clarify, I think part of what we're starting with is like this is very different than the
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psychedelics, right, which are seeding our consciousness in these deep centers of the
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brain, right, whereas what MDMA is doing is sort of flooding with positive neurotransmitters,
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right, in certain parts of the brain.
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And I think what that creates is a greater permissiveness inside to entertain or approach
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different things, right.
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So I think where we see it's tremendous, my read of the data is around potentially and
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we're seeing in some of the trials, right, tremendous benefit for trauma, right.
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And you think about what we were talking about earlier, how this reflexive guilt, shame,
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hypervigilance avoidance, right, and when these systems are flooded with these neurotransmitters
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it's more permissive to sort of think about that, right, and to think about that without,
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again, all the chatter of that's your fault or you're never going to get anywhere because
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of that or you know what that means, right, they can kind of go away and then we can think
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about it in a way that isn't through the lens of fear, right.
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And I think that's the power there is that it's permissive of approaching something,
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contemplating something, you know, a different, a novelty.
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We talk about a de novo approach and I think that's also why the experience can vary
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because you could also see how if you're not thinking about something, right, so there's
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not a clinical guidance to it, you could be in a state where like I just feel good, right,
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and I'm thinking about good things and like that can feel good, right, but that's not
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necessarily problem solving, right.
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So the clinical guidance says, hey, let's take that state and do something with it,
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right, now that you're in this state, hey, let's make cable, the sun is shining, right,
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you're in a state where we can look at things that are traumatic, right, we can approach
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them from a de novo perspective and I think it's part, I think that explains why you
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had these different experiences from one to the other because your brain is just in a
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state that's conducive to something, right, but if there's not the mechanism to have that
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thing happen, like conducive to something therapeutic, then you might go there on your
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own or you might just be in a state where you have a sense of well-being and you sit
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Which sort of seems like a waste to me, I mean this is what I tell people when they
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ask about MDMA, I said at least from my experience that the potential hazard there is that in
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that very high dopaminergic, serotonergic state, there were moments where I felt like
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I could get excited about any one specific concept that I might even just think about,
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for instance, you know, water and how nourishing it is and really just go down the path of
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water and the world and all the water and you can, you know, you're in a state that
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is very prone to suggestion, internal suggestion and so the guidance turned out, the guidance
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from the clinician turned out to be immensely valuable in allowing me to go into my own
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head for bits of time but then also to resurface and share and exchange in a way that to, I'm
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trying to really get something out of it that was useful and that I could export because
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of course water is wonderful but I'm not really interested in growing my relationship
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to water and I really felt like I could understand for the, I never went to raves or anything
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growing up, I never did MDMA recreationally but I understood for the first time how people
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could get really attached to an environment and feel connected to things because I think
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with all that serotonin, you just feel connected to everything around you so I think it's
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a slippery slope there and I don't know what the future of the clinical use of MDMA looks
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like but I would hope that whoever's thinking about guiding these sessions is really thinking
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carefully also about evolving the practice to help people really move through in a sequential
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way so they can leave with something valuable.
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Yes, 100% and 100%, these are such powerful tools and if they're powerful tools and we're
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using them without respect for them, right, without clinical guidance, we incur risk,
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right, I mean you know getting obsessed with water, well and it probably isn't going to
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hurt you, right, but if someone is out using it, there's around other people, what one
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can feel positively about or become sort of obsessed in the short term about can be very
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counterproductive, right, there can be a lot of risk to that so I think it anchors back
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to these are very powerful tools, we're coming to understand them much much more and we're
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coming to understand that they have immense potential to be helpful to us but I think
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and hope that that only also increases our respect for those modalities and what can
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come, what negative can happen if we're not respectful.
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This can be very interesting to see where all of this goes in the next few years, not
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just in Oregon but elsewhere, it's one way or another, it's happening, it seems to have
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a momentum that is not going to stop so very exciting area to be sure.
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I have a question about language.
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In your book, you talk about how we need to be careful about the use of language around
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trauma and maybe problem solving and problem describing in general, you know, on at one
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extreme you hear that your brain and your body hear every word you say and you know
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we have to be so careful with language and that actually frightened me for a number of
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years because I would hear that and I thought, gosh, if I just think that something is bad,
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now it's going to hurt me worse, which itself is part of that whole, you know, packing
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down of an issue, very hard to avoid thoughts without distraction.
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So that's one extreme.
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On the other hand, you know, I can say, I can tell somebody I love them with a tone
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of hatred, I can tell somebody I hate them with a tone of love.
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So how should we think about language in parsing trauma?
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And in your book, you talk about, you give some cautionary notes about talking about
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depression, trauma, and PTSD in terms that might diminish their real severity in some
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cases and I was really struck by that.
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So maybe just touch on, you know, how should we talk about these things in a way that doesn't
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diminish them for ourselves or for other people and at the same time honors the fact that
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there's a lot of trauma out there and there's a lot of depression out there and we need
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Yeah, I think this is a very complicated and in many ways convoluted topic.
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Like I think it's wonderful that we have language, but boy, language leads us astray
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You think about how we, how people define words.
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Like what, someone says a word, what is it, does a person know what that word means?
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What nuance are they taking from it?
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That we just have to be very careful what we're saying and what we're communicating.
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And I think this doesn't mean because, you know, there's a sort of phenomenon now where
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people are trying to control language, I think too much.
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Like you can't say anything that someone else might find hurtful.
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You have to refer to people in ways they choose to be referred to, even if those are ways
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that others don't understand or ways they themselves have decided or ways that might
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be psychologically or clinically unhelpful.
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So I think the overcontrol of language is not good, but I think the specificity of language
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of what are we trying to say, how are we defining it, even the word trauma.
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We're talking about trauma, so we want to define what that means, right?
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It doesn't just mean like anything kind of negative, right?
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Because then that dilutes it down to meaning nothing, right?
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It also doesn't just mean, you know, injury in combat, right?
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Like we have to talk about what that is.
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So I think anchoring it to something that rises to the magnitude of overwhelming our
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coping skills and changing us, like then at least I define it that way and I can communicate
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that to you and we can understand what we're talking about, right?
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I think that another aspect of language, while again we need this middle ground and I don't
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think that it is okay for the overcontrol of language to shut down expression, but we
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also have to acknowledge, you know, how we're so much less distanced from each other through
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social media and I think social media can do very, very good things as hopefully we're
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But it can also be used to harm people from a distance, right?
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And how much hatefulness is there out there that I think comes from anger and frustration
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in people, you know, back to trauma, right?
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Where people just want to be angry and it's not really issues that they're talking about,
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but then there's a target of that anger and, you know, people feel beleaguered by that
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and the words that people use sometimes are so awful that someone reading that, like if
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you're in the demographic that's being targeted, right?
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And you're reading that, I mean, how does a person not feel, not feel beset upon, vulnerable,
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And then I think that also fuels, you know, things like we just had this terrible shooting
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in Buffalo, right?
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Like just hate motivated, right?
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And I think that because that kind of language becomes very real to people who may take it
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in, it fuels their hate, and then they do something to enact it, which of course creates
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greater fear and vulnerability.
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And I think there was some civility and decorum that was in our world not that long ago, right?
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I mean, you know, I'm in my early 50s, I'm not that old, right?
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But I remember a time when in political discourse, people were civil to one another, right?
link |
Now, so much, I mean, it's not all of it, right?
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But there's an acceptance of things that are just bombastic, right?
link |
There's like, it's a circus sideshow sometimes of people being just angry and aggressive.
link |
And it's not really linked to anything, although it's allegedly linked to something, but then
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other people's anger can attach to it.
link |
And it's not about what it's about, but it's about aligning with the anger.
link |
And I think that there is so much damage that comes from that.
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And I think, you know, should we have, should it be okay that people sometimes are talking,
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communicating, using language in ways that would like get us suspended from middle school,
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Ways I don't want my eight-year-old to see.
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I mean, is that really okay?
link |
Or do we need to take a stand for the rational use of language?
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I don't want my use of language to be over-controlled by someone who thinks they sort of understand
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better than the rest of us, how to communicate with those, okay?
link |
I don't want that.
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What's stereotypically a sort of idea of the left, say, right?
link |
At least in our society.
link |
But I also don't want language that can be so angry and so aggressive that it is perpetuating
link |
or spreading vulnerability and that it facilitates trauma.
link |
And I think we could set standards as a society where we say, look, I don't want anybody in
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power who's going to behave that way, right?
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I don't care if their whole agenda is like, make Paul Conte's life better.
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I'm still not going to vote for you, right?
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If you're behaving towards others in a way that's denigrating, you're behaving in a way
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that I feel essentially ashamed of, right?
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And I feel that a lot, right?
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I see the politics, you know, I see things play out.
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It's not always political, of course, not always political, but I see things play out
link |
and I think, oh my gosh, I feel embarrassed.
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Like we're somehow okay with this.
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Well, it doesn't matter which side of the political spectrum it's coming to.
link |
And I think that's an indicator that what we're doing is really hurtful to us.
link |
People become more angry.
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They attach to the anger.
link |
People feel more beleaguered.
link |
There's more divisions between us and it seems more and more like, well, we can only really
link |
identify with people who are just like us and like, what does that really mean?
link |
I mean, the divisions that it creates between us and that, you know, that promotes so many
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negative things, right?
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I mean, think about ways in which it promotes white supremacy, right?
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It's just one example, right?
link |
And we've seen that play out that this is really bad for us and we've got to look at that.
link |
I mean, if we don't look at that, I don't think it's always something is going to happen.
link |
Like something is happening, right?
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It's happening now.
link |
And it really, to my mind, it really seeps down into the soil of everything that we're
link |
talking about on all sides.
link |
People are activated.
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People are upset about one thing or the other, right?
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No one is immune from upset regardless of political affiliation and everybody seems
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to be upset nowadays.
link |
And as I was hearing you talk about this, I feel a lot of resonance with what you said.
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And I also am hoping you run for office.
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I don't think I have the gumshoe for that, but thank you for that.
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Oh, that would be wonderful.
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I'd like to talk about a concept of taking care of oneself.
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This comes up in the book.
link |
This is something we talk a lot about on this podcast.
link |
I mean, I think people have heard me blab endlessly and I'll probably go into the grave
link |
telling people to get sunlight in their eyes when they can and to try and get proper sleep
link |
and to have a few tools for reducing their anxiety in real time and on and on and on.
link |
You know, we hear about this concept of taking care of oneself and I think at a surface level,
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it can sound a little bit light.
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You know, oh, take care, take care, take good care.
link |
You know, but to me, it's a deep and powerful concept.
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And I was very happy to see it in your book and also to learn a lot of ideas about what
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that really looks like because whether or not somebody is in the early stages of considering
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whether or not they have trauma or is in the deep stages of working that through or has
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made it through the tunnel some distance, taking one care of oneself is an ongoing process.
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I'd love for you to just describe what taking care of oneself means to you as a clinician.
link |
And of course, the practices and things that you encourage people to do.
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But how should we think about taking care of oneself?
link |
Because on one extreme, you could imagine massages or treats, vacations and chefs for
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hire that take care of everything for ourselves.
link |
And on the other extreme, you could say, you know, leaning into life in a way that you're
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paying attention to small things while working very, very hard.
link |
So, it's such a big concept.
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But how do you think about taking care of oneself?
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How should I take care of myself?
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How should people take care of themselves?
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I see here what I think is a very fascinating dichotomy, right?
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That in some ways, think about how complex our brains are, right?
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How complex our psyches, our unconscious minds are.
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There's so much complexity there.
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But on the other hand, psychological concepts that are consistent with health are often
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very simple, right?
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By which I don't mean light, right?
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But simple, straightforward, right?
link |
And I think self-care is absolutely one of them.
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I mean, how much is talked about how to take care of oneself that just skips over the basics
link |
that are necessary as a building block for all else.
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It doesn't matter how many chefs or vacations or whatever a person has if the basics of
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self-care aren't squared away.
link |
And it's not a light concept to say like, look, are you sleeping enough, right?
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Are you eating well?
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Are you getting natural light?
link |
Are you interacting with people who are good to interact with, right?
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Are you accepting negative interactions in your life?
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Are you living in circumstances that make you feel okay or not?
link |
They're very, very basic premises, but so often we're not looking at them at all, right?
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We're not looking at them at all because we tend to skip over them.
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And we tend to skip over them either because, again, in some automatic way that sometimes
link |
is trauma-driven, we're not going to look at that, right?
link |
And often not taking care of ourselves can have the punishment, distraction, right?
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There's so much that can come into that or our sense of power is tied to not taking care
link |
I mean, an example is I tend to, for whatever reason, do reasonably well with very poor
link |
And like that was very adaptive when I was in some medical training, right?
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And I'm like, okay, I can eat a lot today.
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I can not eat, right?
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I can sleep two hours.
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I can sleep eight, right?
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I mean, overall, that's not good.
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And it hasn't been good for me as I've aged, but then I realized something.
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Look, I'm doing all these things that make myself healthier, but like what?
link |
I ignore that, right?
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And why am I ignoring it?
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That was a key question.
link |
Why am I ignoring it?
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Because somewhere inside of me as it was, and still to some extent is, this idea that
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my ability to be really functional, right, to generate success in the world around me
link |
is tied to my ability to do that, right?
link |
But if I stop doing that and now I'm eating and sleeping regularly, then I'm going to
link |
lose some edge and so even I think about this all the time, but I realize, hey, I'm also
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I'm not doing it inside, you know?
link |
And I think it's really grounding to the basics that really help us of like, what are the
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basics of what I'm doing and not doing in my life?
link |
Diet, exercise, sleep, people, circumstances, leisure activities.
link |
I mean, I think immensely important and dramatically undervalued.
link |
Well, I want to thank you for that and I want to thank you for today's discussion.
link |
I found it to be incredibly informative and I know our listeners will also.
link |
I also want to thank you for the work you do.
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I mean, you obviously run an incredibly robust clinical practice that I'm aware that you're
link |
constantly trying to improve, even though it's operating at the highest levels already.
link |
I appreciate that.
link |
And I really, the reason why you're here today is because I've done a wide and deep
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search for people in these areas.
link |
And there are so few who have the background in medical training and physiology in the
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psychoanalytic and psychiatric realm and also have a grounding toward the future, you know,
link |
of what's coming and who can encapsulate so many different orientations and bring them
link |
together into a coherent piece.
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So I really thank you.
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Yeah, and for your book, which is incredible, I will go on record saying I think this is
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the definitive book on trauma and I really encourage people to read it and will continue
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to encourage people to read it.
link |
It's so many valuable takeaways and insights and tools there.
link |
So on behalf of the listeners and myself, thank you so much for joining us today.
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You're very welcome and I take that to heart and I'm very appreciative of being here.
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So you're very welcome and thank you as well.
link |
Thank you for joining me for my discussion with Dr.
link |
I also highly recommend that you explore his new book, which is trauma, the invisible epidemic,
link |
how trauma works and how we can heal from it.
link |
It's an exceptional resource, both for those that have trauma and those that don't have
link |
trauma or those that suspect they might have trauma.
link |
Again, it's a deep dive into what trauma is and offers many simple tools that anyone can
link |
apply with a therapist or not in order to heal from trauma.
link |
And if you'd like to learn more about Dr.
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Conte and the work he does directly with patients, please check out his website, pacificpremiergroup.com.
link |
We've also provided a link to both the book and pacificpremiergroup.com in the show note
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If you're learning from and are enjoying this podcast, please subscribe to our YouTube channel.
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That's a terrific zero cost way to support us.
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In addition, please subscribe to the podcast on both Spotify and Apple and on both Spotify
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Please also check out the sponsors mentioned at the beginning of today's episode.
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That is the best way to support this podcast.
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Not so much in today's episode, but in many previous episodes of the Huberman Lab podcast,
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we discuss supplements.
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While supplements aren't necessary for everybody, many people derive tremendous benefit from
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them for things like improving the transition time and the depth of sleep each night, for
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improving focus, for managing anxiety, and for many other aspects of mental health, physical
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health, and performance.
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For that reason, the Huberman Lab podcast has partnered with Momentous Supplements because
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first off, they are of the very highest quality.
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They also ship internationally, which many other supplement companies do not.
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And we wanted to have a one-stop location where people could find and access the supplements
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that are discussed on the Huberman Lab podcast.
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So if you go to livemomentous.com slash Huberman, you will find many of the supplements that
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are commonly discussed on the Huberman Lab podcast.
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I should just mention that the catalog of supplements there will be expanding in the
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weeks and months to follow, but already a number of them for sleep and focus and other
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aspects of mental health, physical health, and performance are already there at livemomentous.com
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If you're not already following Huberman Lab on Instagram and Twitter, please do so.
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There I cover science and science-based tools, some of which overlaps with the content of
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the Huberman Lab podcast, but much of which is distinct from the information covered on
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the Huberman Lab podcast.
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We also have a newsletter called the Neural Network Newsletter, where we offer distilled
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So lists of protocols and key takeaways from podcast episodes.
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If you want to sign up for the newsletter, all it requires is your email.
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Please know that we do not share your email with anybody.
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We have a very clear privacy policy.
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You can find all that by going to HubermanLab.com.
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There's a menu there where you can sign up for the Neural Network Newsletter.
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You can also immediately get access to some example newsletters.
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So you know what the newsletter is all about.
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So thank you once again for joining me for my discussion with Dr. Paul Conte.
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And last, but certainly not least, thank you for your interest in science.