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

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