The Peter Attia Drive - #15 - Paul Conti, M.D.: trauma, suicide, community, and self-compassion

Episode Date: September 17, 2018

In this episode, psychiatrist Paul Conti, M.D. discusses the impact of untreated trauma, the rising rate of suicide, and the influence of modern society on mental health, to name a few important topics covered. Paul also talks about how to deal with these challenges for yourself, your loved ones, and the community at large. We discuss: Paul’s background, and what drove him to psychiatry [5:00]; How silent bravado and incessant striving can lead to a functional (and actual) death, and why Paul is critical of the current state of psychiatry [14:45]; Psychedelics, psychotherapy and the dissolution of the ego [20:30]; How current society may be contributing to the increasing amount of suffering [25:00]; The ubiquity and impact of untreated trauma [31:45]; The rising rate of suicide, parasuicide, and “accidental” death [35:30]; Types of trauma, why we minimize it, and Peter’s introduction to Bridge to Recovery [44:00]; Triggering shame and fear, childhood trauma, and why trauma doesn’t care about time [48:00]; The impact of the brain on the body, and overcoming trauma with self-awareness [55:00]; How to recognize and stop the cycle of shame transference [1:04:30]; Peter’s profound experience at Bridge to Recovery, and the importance of finding shared experiences with others [1:11:15]; How to identify and deal with our own personal trauma [1:19:00]; Finding meaning in struggle, why we are less happy than ever, and the impact of an isolated society [1:25:30]; What steps can we take as a society to make an appreciable impact on the rising sense of desperation and misery? [1:43:15]; Resources, book recommendations, and things you can do [1:56:15]; and More. Learn more at www.PeterAttiaMD.com Connect with Peter on Facebook | Twitter | Instagram.

Hey everyone, welcome to the Peter Atia Drive. I'm your host, Peter Atia. The drive is a result of my hunger for optimizing performance, health, longevity, critical thinking, along with a few other obsessions along the way. I've spent the last several years working with some of the most successful top performing individuals in the world, and this podcast is my attempt to synthesize what I've learned along the way to help you live a higher quality, more fulfilling life. If you enjoy this podcast, you can find more information on today's episode and other topics at peteratia-md.com.

Welcome to this week's episode of The Drive. My guest this week is one of my dearest friends, Dr. Paul, Conti. Paul is a brilliant psychiatrist. In fact, I often refer to him as the single best psychiatrist I've ever come in contact with, and I've met some many very sharp people over the years. I've long wanted to have Paul on the podcast. I've always wanted to interview Paul just in general because there's not that many people who I find myself having discussions with

and I think to myself, how can this discussion be shared with others? And throughout this interview, you'll hear us even comment to that effect, which is God, it's almost like we're not even talking in front of microphones. This is exactly the kind of conversation we find ourselves having so often.

Paul's a very special person. He doesn't get into great detail, but his life has been shaped by a number of really, really tragic events, a couple of which he alludes to here, many of which he does not. In fact, some of the most tragic events in Paul's life, he does not allude to. But I think the point that comes across here is that Paul is one of the most empathetic, kind, giving individuals and his understanding of the human condition is really unparalleled. So in keeping with one of the general themes here, which is longevity, of which health span and happiness are important components, we go really deep on this topic. We talk about what is meant by trauma.

Many people just think of trauma as, you know, you got hit by a car or something like that, but we get really into emotional trauma. We talk a lot about shame, which is the result of trauma, and what it ends up doing. We talk a lot about depression, suicide, and a number of other topics that are closely related to this. I do think at times this

is a little bit heavy, but we really don't get into any of the technical stuff that I thought we might get into in large parts just because I think there was so much to talk about without getting into the neurobiology. I do think that Paul and I will need to sit down again in the future and get a lot deeper on some of those other topics that I also thought, you know, would be interesting and I suspect a number of you will find very interesting. So again, this is not a deep podcast from a technical standpoint, though we do get into some of the heavier stuff. Unfortunately, Paul is not someone you're really going to find much about on social media.

Paul is someone whom can be contacted through his office, of course, and will provide that contact information for folks who do want to reach contacted through his office, of course, and will provide that contact information for folks who do want to reach out to his office. But the good news is Paul is really considering writing a book. And after we finished recording this podcast, we spent another 20 minutes talking about the book he wants to write. And the just of it is the book is exactly about the stuff we talked about today. So I couldn't be more encouraging of Paul doing this and I think that the world will be

a better place for that. So I hope you enjoy this episode. Half as much as I enjoyed listening to Paul talk about all of these things and I think almost anybody will find something of great value in this episode. Hey Paul, how are you man? I'm doing well Peter, thank you for having me. You're a super trooper here, you have laryngeitis. I do indeed have laryngeitis, I am persevering and I appreciate your patience in persevering

with me. Well luckily, I guess luckily is the wrong word but most people here don't know what you sound like normally so they probably won't even know that you're that. I'm only bringing it up because I know you're straining a lot to speak, but this is such an important topic. We didn't really want to put it off, but you know, two of us were so busy, even though we're in New York off

and that we could both have a night when we don't have something else to do, I think makes this worth it, so thank you. It's in my pleasure, and even though I sound like the Godfather, I'm still going to do my best to come across as open and honest in a way that's not quite consistent with the Godfather. Although you did pull one old school Italian trick a moment ago, which was as you came in my apartment, you beeline for the kitchen. What did you do with the aspirin? I gargled with hot water and aspirin, just like my grandmother taught me to do.

She gets credit if people can understand me. Credit goes to my grandmother. All right, so there you have it. Your first old Italian old school trick on what to do at Lerangitis to take some boiling water, smash some baby aspirin into it and gargle it. They didn't teach us that in medical school, but I'm still doing it. All right, so speaking of medical school, you and I have now known each other for 21 years. Amazing.

Yeah, almost exactly 21 years. And I think the relationship that you, me, and the other five coconuts had in our med school class, the seven of us, probably in some ways really annoyed most of our med school classmates, because we were, we became close like within the first week of school and never separated. We were just we were an inseparable group of knuckleheads that I strongly agree that that annoyed people. Yes, yeah, yeah, it did. But we're fortunate and I feel blessed to to have met all of you guys and in particular probably of all of the seven of us now, I think you and I by far spend the most time together because so much of our work clinically overlaps. I don't want to go deep so soon, but I think I feel like I have to.

So I'll never forget the first day we met. All med students on day one are sort of nervously talking about why they're here and blah, blah, blah. Truthfully, most med students don't really know what they want to be when they grow up. They have sort of figured out they want to be doctors, and that's about it. But there were some of us that knew I wasn't really one of them. I kind of knew I wanted to do something in oncology. I thought at the time pediatric oncology, one of our buddies decided on day one, he was

a plastic surgeon, and that's exactly what he is today. You said the most interesting thing I'd ever heard, which was that you wanted to be a psychiatrist. And I just remember thinking, I didn't know people went to med school to become psychiatrist. I thought that was sort of a lifestyle choice that they made later on or something like that, but you were adamant about it. Why was that the case? I think it represented a search for truth. I think it represented a search for truth and probably a response to some of the difficult things in my life and to a lot of the dissatisfaction that I was feeling with achievement with my personal life, my professional life from top quickly, you know, this group of us became really fast friends.

And I think there was a commonality there that we'd all had some life experience. And in different ways, as we came to learn, we'd all really been through a lot. And I think we were coming into medical school, searching for something. And trying to find that something for ourselves, through doing things that are good for other people. And I understand that the idea is that's why people go to medical school and I'm not saying other people weren't doing that, right? But we'd all been through a fair amount

and I think it's the suffering component that drove the ability to maybe be open and honest earlier with one another and to form bonds that were based upon the searching that we were all doing that drove all of us right to change career to do something different than what we might have thought we were doing as a response to an internal need. And I think ultimately as a response to trauma. It's interesting you've read that up.

I mean, I always knew this, but I guess I sort of forgot until you reprimed it. None of us were pre-meds, and all of us were a little older. We were all a couple of years older because we'd all, in some cases, like in Bobby's case, I mean, Christ, he'd been a mountaineering instructor for a decade or something like that. You know, Zolly had been in the army for four years, same with Jason, all these guys. Sorry to be calling all our boys out here on the show, but yeah, none of us had just come through. Right, right?

And certainly people can go through a lot by the time they're out of infancy, right? So it's not as if people need to be at a school, do different things in order to really gain life experience. But I think the choices that each of us made were choices that came from a place of drive and ambition, but ultimately that were colored by very personal things. And I think lead each of us to really want something more. And I think we came to medical school and part to find that.

And I don't think that there's a distinction between what are the things that we do for other people and the things that we do for ourselves. I think that that's a false dichotomy that follows through sort of Western logic that things have to be one thing or another. And I think often the best things that we do for others, we do in a search for some healing or soothing in ourselves. And I think that that was part and parcel of all of us. It was part and parcel of, I mean many people that you and I went to medical school with

trained with, but I think it's what made the seven of us fast friends. And I think it's why there's remained a strong bond in part because that searching and that desire to do for self-through doing for others I think really hasn't changed. So what were you doing before medical school? In other words, you studied, you were an undergrad and you went to Penn, you studied math and then you moved to New York, you were working in finance, right? Yeah, I minored in math, I majored in political science and I studied a lot of history and a

lot of literature and a lot of literature. What I didn't realize was that the attraction to me of everything that I was studying was really the allure of people. I studied World War II a lot and for a while I thought I wanted to go to grad school and be a World War II historian. It's something I realized what fascinated me was the people, right? The people who were driving the action good, bad or otherwise. You know, the people who were caught in the crossfire as you know, the millions of people who were part of that event. And what I realized over time was that there was a commonality of drive about understanding

what was leading people to do things or how people were responding to things. And oddly enough, it may seem odd, but I think math is kind of part of that too, right? understanding what was leading people to do things or how people were responding to things. And oddly enough, it may seem odd, but I think math is kind of part of that too, right? That there are things that happen inside of people and there are aspects of our choice. Our choice is that we design with a certain linearity, but ultimately, you know, they're complex functions in all of us that make things that we might think are predictable, very unpredictable. And I only kind of realized that in retrospect.

I mean, when I graduated from school, I had some really good job. And I came out in 1991, and there was a little bit of an economic downturn, and I was fortunate to get a job with a good consulting firm. And I just thought, okay, that's where I'm gonna go. You know, then I'm gonna have this business career. And if it's with my father having been entrepreneurial and had a business career, and I just thought, okay, that's where I'm gonna go. You know, then I'm gonna have this business career. And if it's with my father having been entrepreneurial

and had a business career, and I just thought, like, okay, that's for me, and I'm gonna make my way doing that. So then what changed? Well, changed is it really, really did not make me happy. And I say that with no criticism or dispersion, whatsoever, to people from whom, if you don't, it doesn't make happy. But there was something very much missing from it for me, and I think that was the intensity

of human interaction, and so the intensity of human struggle, and what I found is, you know, I did that for four years, and I took some time in the middle, and I traveled for several months because I was kind of trying to figure something out, like why am I not happy, right? And I came back and I took a better job with the same company, right? So as time went on, you know, I had more authority, I was making more money, I was doing more interesting things

and I was less happy. And it really became quite stark to me that unless I was delving into like the intensity of what's going on inside of people, I wasn't gonna be happy. And I think what I didn't really fully realize was that that was gonna be a way of kind of delving into the things going on inside of me.

And I mean, as you know, and I've talked about many, many times, there were some traumatic things that happened during that time that really just brought to the fore to me. I want to understand better and I want to be able to help soothe things in other people. And what I didn't realize at the time was that wasn't a way of saying, oh, I'll be selfless and altruistic, right? And like that's going to save the day for me. But really, you know, that also what I didn't realize at the time was the mirror that

it would put up that would allow me to like just get access to help that I didn't have before, be open and communicative and understand myself in ways that it wasn't necessarily programmed to do, right? I mean, I was programmed to like work hard, achieve, not be weak, right? And that inability to express, right, even to myself, let alone to other people, you know, was ultimately draining the life from me and actually did, you know, drain the life in terms of like actual death from some people around me that I very much cared about. And in some ways, I was rebelling away, we were belling against that way of being

in the world and that way of teaching people to be in the world And I had some I think inkling of understanding of that But it more came through anger and and rejection of things and it came through an understanding Through the lens of compassion that you know, we've kind of structured our society in a way that makes it very very difficult to live in that I think you're alluding to Obviously something I know is very difficult. And we've talked about it a lot. I don't know that we need to necessarily go into great detail here. But in the span of a year, if I recall, you lost your brother and your best friend.

My brother died by suicide. And about a year later, one of my closest friends, so this same, a close group of friends growing up, it's sort of like we had in medical school but there were a group of us and one of those very, very close friends from childhood also died and he didn't die by suicide but there was sort of that same kind of desperate recklessness that I saw this common route in those two deaths

and they confused me and infuriated me and made me feel very helpless and vulnerable and wanting to be able to understand better and to fight against this thing that made it so hard for people to get help and to be vulnerable. made it so hard for people to get help, right? And to be vulnerable, and that was really the commonality is like both of the people who died, had real and significant needs inside of them that came about naturally, right? Like something you one would never criticize

a person for having those needs, right? Over those struggles, but there just wasn't a venue of getting real acknowledgement and help for any of that. So that kind of silent bravado and silent struggle, you know, became very real to me that like, oh, that leads to death, right? I mean, it doesn't all the time lead to death, but it leads to death way more often than is even remotely acceptable. I mean, I think as we've discussed,, sometimes it can lead to death immediately, like in these cases, and sometimes it can lead to a functional death, which is you're still

technically alive, you know, you still respire, but you're effectively dead. And in many ways, that's probably the more endemic, more sinister, more destructive over the long term, given its sheer volume problem, right? Oh, absolutely. I think the deaths that we see in front of us as like actually, okay, that person is not breathing anymore are there a viscerally moving hallmark of what is so pervasive in our society. And I do think that I didn't understand that then, that in many ways, the way our society is structured and the way our metrises of achievement are structured really backens us to death and life, to losing touch with the basics of our own value system and essentially

to incessence striving and not incessence driving to achieve, although we may see it that way, but incessence driving to not pause and to not feel the vulnerability that I think is so pervasive now. I mean, even in the 20 years, you know, since we went to medical school, I mean, you think about how pervasive media is, right? I mean, how there's just marker after marker after marker after marker. That says that you're not good enough. You don't have enough.

You're too vulnerable. You know, there could be terrorists. Like any time your kids could be killed, we could die. I mean, it's one stimulus after another that tells us not to stop and to really value ourselves by the things that we really value. We get through med school and true to your word, you get a psychiatry residency spot. You decide to stay at Stanford in part because your wife was still, you're soon to be wife. You guys weren't married yet, but your girlfriend was a couple years behind us in med school.

you guys weren't married yet, but your girlfriend was a couple years behind us in med school. And you end up spending half your time at Stanford, and then your wife matches at Harvard, so you go and finish your residency at Harvard. So whenever I'm telling patients about you, and I'm probably bastardizing all of my knowledge, which is so limited in this field, but I say, you know, one of the things about Paul that's so unique is he did half of his training at Stanford, which is probably one of the foremost institutions when it comes to understanding the neurobiology and the pharmaconeurobiology and the pharmacology of psychiatry. And then does the other half at Harvard, which is sort of a more old school, but you know, a place that specializes so much in the psychotherapy. Is that an act? Am I making that up when I say that?

Because I've just decided to take the liberty and say that about you. It sounds good, so please keep saying it. No, no, actually I think that there is truth to that. And there's even more truth to that. The longer I get from it and the more I reflect on it, I think that I am not a very positive or hopeful person about the state of the field that I'm in, which I think that, you know, I am not a very positive or hopeful person about the state of the field

that I'm in, which I think does not broadly enough train people in brain biology, not just in the use of medicines, but in what those medicines actually do. And on a very real level, what are those medicines doing as interventions in the brain, in the many, many systems of the brain, in the cascade of effects that occur in the brain? And we don't think about structural neurobiology, we don't think about neurochemistry in general. So there's that part of the field that often gets ignored.

And then the other side is the psychology. There has been a debate of should psychiatrists still be trained in psychotherapy. And I see this come up. And I just think that it's a fact for a way of putting it crazy to consider having people that are that are schlepping medicines to other people that aren't thinking about what it's like to really try and understand someone and what are the paradigms of understanding other humans, right? The kind of things that are valid and have a scientific basis for them, but that are not hardcore brain biology.

And I was very, very fortunate to learn so much neurobiology at Stanford and to have that integrated into my training. But when I got to Harvard, I was struck by that several very prominent influential people there who were influential over, for example, whether I graduated, were really shocked at how much brain biology I knew and really shocked at how much psychology I didn't know. And even though I had sought out some of this on my own, being in a place that was kind of steeped in an older analytic tradition really helped me kind of embrace this belief that understanding psychology and certainly from the perspective

of what's psychodynamic, right? The things that influence and motivate us that are in our unconscious, you know, the gigantic part of the iceberg that's underneath the water, but that is most deterministic of our behaviors and our choices and our feelings and being able to integrate that with the brain biology upon which it rests, I think, is, I think it's the way to at least try and have the most broad set of abilities to try and help people. And in some ways, it was very fortuitous for me to split my time between those two places and to find a couple very, very good people who took it upon themselves to try and teach

me in a short period of time. What maybe I should have learned over a longer period of time. When those of us who are not trained in this discipline think back to, you know, our psych 101 class or something is undergrads in college, you get introduced to all of the luminaries in the field. And one of the things I still remember was sort of the IED, EGO, Super EGO stuff. How much of that stuff is still relevant today? I mean, even sometimes when you and I talk, we still, and again, when we talk about personal

things, this idea of EGO still comes up. I mean, you and I both completely separate to all of this discussion, because we won't go down this path, it just takes too long, but we share an enormous interest in psychedelics and the promise that they hold for people. And of course, one of the hallmarks of this is dissolution of ego. So when you think about what someone like me

or someone who's listening to this who doesn't have the training, thinks at a very crude level of, you know, the id, ego, super ego, how much does that still apply to how you think about these problems? I think it applies tremendously on a foundational level.

And the problems we often run into are often about semantics and even among like experienced psychiatrists, the definition of words and terms can obscure any understanding. So for example, in the Freudian concept of the ego, it's much more the whole self. It's the part of self that one can bring in a conscious way to bear on the questions and issues at hand. It's the part of self that can mediate between

the different pulls, right? So that it may be about gratification, the super-aggo may be about what you should or shouldn't do, but ideally it's the ego, the whole self that pulls that together. And that's a very different use of the term ego, then how it often is used these days where ego is a sense of self that essentially indicates a defense mechanism. And the idea of dissolution of the ego through the use of psychedelics is not dissolution of the classic psychodynamic or Freudian ego, which is like the whole self at its most poised and comprehensively aware and empowered. It's more the dissolution of ego as defense.

That we build up over time, I think a shocking number of defense mechanisms that serve us well at the time, but that ultimately are an unhealthy part of the foundation that then gets built upon. So, for example, a sense of insecurity and childhood, and I'm not good enough, and I need to achieve more and I need to please people, You know, we build so much around that that defines us in a certain way, for example, right? That tells us that we must be perfect and we beat up on ourselves over less than perfect because that's how we're gonna make ourselves perfect, right?

And then you can think of all the things that build on top of that, which could be maladaptive friendships, maladaptive romantic relationships, maladaptive career choices, right? There's so much that we can build on top of that. And then in a very strong sense, it's almost as if the true us,

the Freudian ego is surrounded by 90 story high walls that are built to protect us, but actually protect us from real connection with self-un others and real understanding. And some of what the psychedelics, it seems through the phenomenology, the people's experiences, the research, when you put all of that together and you look at it with the brain imaging and the knowledge we have about brain biology is in an amazing way they can take down those defenses which if not done in a therapeutic and a controlled setting obviously can be dangerous but in the right setting opens one up to an experience of self and an experience of the truth of

self that is no longer walled off by all of these unhealthy defenses. So, I mean, it's a long answer to the question, but yes, what's going on in our unconscious, what's going on deep in our brain, the things that we're not consciously aware of are so deeply impactful. So, for it certainly didn't get everything right, but this concept of the unconscious pulls on us

and the ability to integrate those things in a healthy ego that can actually decide and choose, I think is as relevant or more so than ever when there's so many pulls away from authenticity of the self. And then the hope of psychotherapy, just shared human experience and psychedelics is to be able to take those defenses down so we can have an

experience of self that reflects who we truly are, which the vast majority of the time involves acknowledgement of the things that were ashamed of, the vulnerabilities, the things that we've ensured ourselves against, which are often the very things that that keep us away from happiness. You know, I'm, as you know, I'm writing a book now and it's not a particularly easy thing to do. I think it's probably hard even for someone who's a natural writer, but for certainly for someone like me, it's very difficult.

And I'm toying with a chapter that I've been really, really flailing with for the past three weeks. It may not end up in the book because I just don't know of how to write it. But it's a chapter that centers around the experience I had in Kentucky, which might seem like an obscure thing to write about in a book about longevity, but of course, as I've become very clear on lately, I don't think all of this obsession with longevity and living longer and living better means a lick if you're miserable. And so much of our misery is self-imposed. And I think, obviously, you are the reason I went there. I would never have done what was required to go through that experience

where it not for you insisting on it. And frankly, even had you insisted on it at a different time without the confluence of events that led to it. I probably could never have done that because the vulnerability that's required to do and to go there and you even put me in touch with another patient, who you had sent, who had gone. Again, the thing that amazed me about that was how long I had lived my life, never even considering the idea that there can be a child that gets wounded, that

wounded child develops in an adoptive child. And sometimes that adoptive child is the one that shows up in the adult body and not as opposed to a functional adult. Yes. Yes. And I guess I just sort of feel like I'm Neo in the matrix and after I've gone through this whole experience, I see my life in a totally different way.

And I realize, oh my God, like all of that achievement, all of that perfectionism, all of those things I was chasing, it's basically a kid trying to protect you. And I've certainly not held out any hope that it's gonna be ever fully resolved. I mean, I'm not, I don't know, maybe I'm just too pessimistic. It's going to get better.

I'm absolutely confident because it has gotten better. But it just strikes me as so hard-wired that it kind of makes me wonder, like, is this something that's getting worse, or is this something that has always existed in our civilizations and our societies? And only now, because so many of our other needs are being met. You know, none of us, if you're listening to this podcast, you're probably not worried about where your next meal is going to come from. You're probably not worried about a plague. You're probably not worried about, hopefully, you're not worried about a civil war or something

like that. So is it just that our basic needs, you know, of the Maslow's hierarchy of needs, that they've been met? And so now we have the quote unquote luxury of worrying about self-actualization and what does happiness mean and what does it mean to be fulfilled in content that we're now realizing this? Or do you think there are things that are actually making it worse today? And there are more wounded kids out there and more adults that are effectively nothing more than adoptive kids?

It's such a fascinating question. And I mean, of course, I don't know the answer, but I do suspect that we are making it worse for ourselves in ways that we haven't intended. So of course, look, I'm all for opportunity. Meaning like we are numbing ours, we have more net and agents to numb and soothe ourselves. No, we've made more opportunity for ourselves in certain ways, right?

And that opportunity is a wonderful thing in many ways, but every good thing has its potential for a downside and something that can work against or even negate the good thing. So for example, as far as I know, for generations, the people in my family lived up in the hills of Central Italy and as far as I can tell most of them were shepherds, right? And we could look at that and say, look there's a there's a limitation to what they could achieve and how fortunate am I that people sailed across the Atlantic and now I go to college and I have a business career and then I go back

to school and I take undergraduate classes and I applied a medical school after all of that and I get in and you could like you could you could list forever the additional opportunities that I have that people didn't have before. And that's wonderful. And I, and I certainly would not argue against opportunity, right? But it also brings greater opportunity to run away from the things that plague us. So for example, you and I and probably many, many, if not most of the people listening to this podcast are driven to be powerful. So, okay, some of the motivation for what I do or what you do is intellectual curiosity that desired it, help others that desired to learn about self, right? But a significant aspect of the strength of the fuel in the tank, right, is running from something, right?

It's running from vulnerability. Because there's more opportunity there are higher expectations. And I think there are high expectations for both of us, not that I am arguing against, you know, the fact that our families instilled in us conscientiousness and ambition. But I think we internalize that as must be perfect,

must achieve more, like when is enough, enough? And it becomes very, very unclear and it becomes very, very unclear, and it becomes very easy to run from things. And you know, it's that that I think that the modern world doesn't actually help us define what we are striving for. So more striving, more power, whatever that means, right? It could mean money, it could mean prestige, and titles, influence, whatever it means, like more And it could mean money, it could mean prestige and titles, influence, whatever it means, like more of that by definition becomes better.

And we live in a world that constantly reminds us of our vulnerability. So there's never a time. I mean, my guess is having spent time in places where people are shepherds, right? And people do have these simpler lives. And sure, they don't have the opportunities we have. But there are ways that I often can see them at the end of the day feel a sense

that the day is over. And that what's the day's exigencies are over. The days ambitions are over, right? They're like things are okay, and it's time to rest, and there'll be tomorrow. And I think most of us don't have that feeling, You know, most of my life, when I fall asleep, I'm exhausted and I have a sense that, well, now I need to sleep for a little bit so that I can get up and strive more. And I don't think there's any way, if we're honest with ourselves,

that we can frame that as, oh, that's a drive to something. Now, that's a drive away from something, right? And it's running away from ourselves and it's running away from our problems. And we don't even know what those problems are. And the fact that, as you know, I have a pretty diverse practice, right? That really, I think spans the spectrum of psychiatric and neuropsychiatric things. And I absolutely believe, and I've come to believe more and more and more and more as time goes on,

that 80% of what I treat is trauma. 80% of what ails me, 80% of what ails you, 80% of what ails, the world around us is all trauma. There's another 20% that might be a head injury, schizophrenia, you know, the complications of physical injuries, biological determinants of addiction. I mean, but, but none of those things, even those things that, that seem and are very biologically determined are free of the impact of trauma and the rest of it, I think, is purely trauma. Its manifestation is anxiety, depression, panic attacks, choices to abuse substances,

choices to do things that are unhealthy, whether it's overeating or it's cutting or it's Gambling or whatever it is that we're doing so much of that is driven by trauma and and I think that you know Yes, it's an opinion, right? It's not something I can prove that you can prove like a you know like a math problem, right? But I think if you really look at it and you look at what's going on at the root of what ails people, I think it becomes self-evident. That I think there actually is a way of proving that, which is just look at what's really going on in people. Instead of categorizing them, you know, there's a DSM-5 that's a half a city block long, that just looks to like, look if we flip through it, I don't know how many diagnoses you and I would have between

us, right? Because it's designed to capture everybody multiple times over, but categorizing what else somebody and putting a number on it is not understanding them. That is not synonymous with understanding them. This is the tragedy of your profession, right? Yes, that's the direction it's going in. I mean, it's designed to categorize. If you categorize something, you can put a number on it, and then you can get 20 bucks through insurance,

and you haven't actually understood people. I think that both the practitioners in my field and the people who come to care deserve better than what the field gives them. And we've stepped away from really trying to understand people. And I'll give you an anecdote. I was very, very fortunate when I was interviewed for Stanford. I was interviewed by Peter Rosenbaum,

who it was an emeritus professor of psychiatry. This was in medical school for residency. No, for medical school. Yeah, and we got along really, really well, and it's a wonderful person. And later on, when I decided to become a psychiatrist, I told him, you know, I got to see a lot of the archives, and I told him, and he, I got his email out of the archive and I told him

and he sent me some redacted histories of patients. And he wanted me to understand that yes, there have been so many biological advances. There's space age, general imaging. There's an understanding of brain biology that was unimaginable 30, 40 years ago, but if you look at what they were writing about people, they really evokes a human being. Whereas very often now, when I look at reports of people, I can't tell anything, right? It's just it's an inventory of signs and symptoms that you could conclude anything from. And then a number gets put on top of it. And yes, I mean, I'm being critical of the field as I'm saying this, but in many ways it's a societal criticism, right?

It's a criticism of a society that dumbs things down and that doesn't respond to the individual, whether it's the incessant phone trees that prevent us from ever solving any problems, right? No matter what it is, whether it's my banker, it's the phone company. I mean, when do you actually connect, right? And I think it's that isolation that is a societal malady, and it affects psychiatry, which is a very bad thing because psychiatry is trying to help us have better mental health, and we're kind

of disarming its ability to do that, I think. And then it pervades our society in a way that leads to isolation and desperation. And, you know, desperation. And if you look at suicide rates and just levels of general misery, I mean, I don't wanna glorify the past, including the recent past, but it's pretty hard to look at that and to think that there's not something here that's getting worse.

Yeah, well, I mean, touching on that, there was an article in the Wall Street Journal recently after the sort of very close to back-to-back suicides of Kate's Bay and Anthony Bourdain. It showed some stats from the CDC. These are obviously US-based statistics. When you looked at men and women between the ages of 40 and 60 across the board, there was about a 30% increase in the rate of suicide.

Over, I don't want to be misquoted on this. It was either a decade or two decades, but it was a relatively recent period of time. And my approach to longevity is very, it's very collugy, right? I mean, I'm kind of a hack if you really stop to think about it. I don't have like some single magic pill that I think can make you live longer.

Instead, it's like a whole bunch of reverse engineered problems. And one of them is, you know, it's, you figure out what it is that's going to kill you and start to back out of that. And so I spend a lot of time pouring over actuarial tables and looking over mortality trends and trying to understand how they're shifting where are we quote unquote winning and where are we losing. And it seems to me that, you know, even though most of my energy focuses on three things,

atherosclerotic disease, cancer, and neurodegenerative disease, the only disease that shows up in every single decade as a top 10 cause of death outside of the first decade, so birth to nine, is suicide. Accidents do as well, but the nature of accidents, by the way, changes so much from beginning to end that it's a very different, in other words, the accidents that kill, you know, 30-year-olds and 40-year-olds are quite different from the accidents that kill 80-year-olds and 90-year-olds. And sorry to interrupt, but how many of those accidents, especially ones that are killing

younger people, are what we might call a parasycidal, right? It's people being reckless and getting killed because their mental state is such that they're not invested in staying alive? Not only that, so that's a great point. The other point is when you look at the top three causes of accidental death, it is automotive accident, falling, and accidental ingestion, which of course begs the question, how many accidental ingestions are not accidental? When I was in college, a friend that I grew up with, his dad shot himself in the head.

I remember the Sunday afternoon that it happened. He literally, they all went out to church, like a normal day went out for lunch after, and then when they got back home, his dad went out to the shed and shot himself in the head. Probably one of the saddest lessons I ever learned was maybe two months later during finals. My mom said, so and so, my friend is not doing well.

He's really down in the dumps. You ought to come home and see him this weekend. I still to this day just cannot, I can't believe what I'm admitting and acknowledging now. It's so embarrassing and painful to say this, but I said, mom, look, I'm in the middle of finals here, you know, I got to graduate first in my class, right? I have to be the best engineer that ever lived. I'll be done in two weeks.

I'll see him then. A week later, he was dead. Oh, my gosh. I'm so sorry. Now, we don't know, you know, I don't know that he'll get counted as a quote unquote suicide because it was alcohol, barbitually, you know, it was like a cocktail of drugs in his system

and he just never woke up. And again, I only tell that story not because it's, it's just such a sad, it's a sad reminder to me to how to prioritize, that overnight change the way I prioritize things in life. But it also begs the question, his death might not be one that actually gets counted as a suicide, but I would call it a suicide. Absolutely.

I mean, the deaths by suicide are in general the ones that are just very clearly suicide, right? But if you... There's a note written that the gunpowder is on the hand as the gun points at the head, yeah. Right, but so many deaths that are not labeled as suicide actually are suicide, and so many deaths that are not labeled as suicides actually are suicide and so many that aren't someone saying I'm going to kill myself now are the result of An approach to one's life that doesn't value it and wants it to end what gets called paris suicide when you when you when you add those things together those numbers It just undoubtedly are strikingly higher than the shockingly high numbers that we're reading

now. And I've always kept a mental note of if someone I know, which includes, again, I don't make much of a distinction in people in my personal life, my patients, people I consult to, I mean, just humans, right, of what they died of on the death certificate versus what they really died of, right? And it might be auto accident, accidental overdose fall, right? And I'm looking and I'm seeing that that person died of made off that they're so ashamed of what happened to them when they were swindled and humiliated, right?

That person died of rape that was never adequately addressed and the sense of shame and the sense of misery that was imparted on them was never addressed. That person died of childhood bullying, right? That was so intense. They decided that they were this awful, reprehensible person in sixth grade and that never changed. I mean, every now and then, the actual cause of death matches what is, you know, my brain registers is the real cause of death, but very often there's a difference there. And the difference I account for by the role of trauma, the role of trauma that pushes

people to either end their life or to move towards the end of their life, even if they're not overtly acknowledging that they're doing that, which can be a clever way of not having to feel accountable. If the religion says, don't commit suicide, well, ultimately it was an accident or, well, I don't want to leave my kids ultimately. It's an accident. I mean, I'm not saying that in any negative way, but we don't help people to understand what's going on inside of them. And you're talking about how you run your practice

and how you try and understand the routes to not just the longevity, but the healthy longevity. And I would argue, my take on that is that you actually have become the best engineer. Because what you're doing is, as you said, you're reverse engineering to ways of living longer and being healthier. And with so many complex variables, I'm not so sure if it's possible to figure that out

without reverse engineering. And I view it as a marker of your, I truly mean this, your intense and incredible thrown ness, that you look beyond the factors and the reasons for the factors and the reasons that underlie the factors and the reasons for the factors and the reasons that underlie the factors and the reasons. And it's, I think what leads you to have me here instead of someone who could talk more about oncology or cardiovascular pathology, right? The realization that what undergirds a tremendous amount of the things that actually takes someone's quality of life or take their life ultimately has a root in

In mental health right that people who are depressed are more likely to die of cardiovascular disease and more likely to die of accidents Are more likely to become addicted right people who've been through terrible trauma are more likely for all of those things to happen The role of stress in its impact on the immune system and the growth of cancer cells, right? There's a level underneath the things to which we attribute morbidity and mortality that strongly influence morbidity and mortality. And I believe that's true. I mean, I think that 80% of what I treat is trauma, but I actually think I don't know what the numbers are, but I think more than 50% of what everyone treats. Any doctor, more than 50% of what everyone treats, any doctor, more than 50% of what walks through that door is ultimately resting in misery inside of that person that I would

attribute to trauma. And again, it's not my way of saying, oh, we're all suffering in some way that it just kind of denigrates, you know, you know, like when really awful things happen to people. I mean, the problem is we don't take stock of really awful things that happen to people like most of the time. And even when those things are something so overt as, you know, an assault, a terrible loss, right? We can ignore even those things, let alone the impact of, you know, loss of a parent as a child, loss of your friend who moves away, loss of a pet. I mean, like, these are things sometimes that you ask somebody what their inner life is like 20, 25 years

later, and that thing may go through their head a thousand times. And it may be that the loss of the pet is symbolic of they will have no stability, no peace, no freedom. So then it becomes, you know, it becomes the internal symbol of their sense of hopelessness in life, or their sense of infinite striving with no hope of getting where they want to go. So I don't mean to say that in some, I don't know, trite way, but I mean to say it in a way that I do think, if you sit with individual people, you see the depth of that and you see the pervasive

of it. When you recommended that I needed to go to Kentucky, needed to go to this place, the bridge to recovery, which we'll be sure to link to in the show notes here, because I really think if anybody takes anything away from this and they even have a suspicion that there, some of their actions, some of their pain could be sort of driven by trauma that occurred in life. I wanna make sure that people at least pick up the phone, give them a call and at least commit the time

to doing an intake interview with them. But I mean, I was so incredibly resistant to this idea, right, it was this idea that how could there really be anything wrong with me? Look at how hard I work, look at how quote unquote successful I am. And by that I just meant like, I'm not an alcoholic, I don't have a drug problem, I'm not a gambler, like I don't have any of these overt signs of pathology. Yeah, I've got these other things that are kind of pathologic, but I can mostly keep them in check. pathologic, but I can mostly keep them in check. But I kind of remember when I did my intake call with them, how pissed off I got. And that to me, there was two things, right? So the

first is I'm talking to this poor woman whose job it is is to just do a basic screening call. But she's asking me a lot of questions. Nobody's ever asked me. And questions, I don't want to answer. And at one point, she asked me a question of questions nobody's ever asked me. And questions, I don't want to answer. And at one point, she asked me a question. I won't tell you what the question was. But my answer was fuck you. Like that was just my answer, right? And when I later told that story once I finally got there,

everybody thought that was so funny, because they're like, wow, she asked you a question about X, and she found out you have X and a bad temper. It's like, wow, she asked you a question about X, and she found out you have X and a bad temper. It's like, it's really great, anger management, and this other thing, check. But that was also kind of the reason, that was certainly one of the things that made me think, because as you recall, you know, you wanted me to go,

and I agreed to go, and then I backed out, and you know, it's just like, this had been something that had been on the table for years, and I just refused to acknowledge this needed to be done. And I think part of it was the semantics, right? It's like, what does trauma mean? We get so far in our lives, our skin gets so thick that I think people get into different patterns. And for me, I know the pattern was minimization. You know, I didn't forget any of the stuff that got me there.

I just didn't forget any of the stuff that got me there. I just didn't think it mattered. You know, when they talk about trauma at the bridge, they really refer to it in five roots. So, the first root is abuse, which can be physical, emotional, sexual, spiritual. They talk about neglect, abandonment, enmeshment, and the witnessing of tragic events. And so I think it'd be impossible to think that somebody listening to this hasn't experienced at least some of one of those branches, and many of us more than one.

For me, the single most powerful way to let my guard down was because we're now what, three or four days into the most intense experience of my life, which is 13 hours a day of group therapy. And I had still sort of, I mean, I was there, so I'd shown up, but I wasn't happy. But I'd refused to sort of even have a discussion about any of this stuff.

I was happy to listen to other people, but I wasn't gonna get into it. And one of the counselors, and I had these two amazing counselors, Jeff and Julie, I can't remember if it was Jeff or Julie, but one of them said something to the effect of, you know, if such and such, because we were talking about an event in my life,

if such and such occurred to your son, Reese, because Reese is four about the age that, you know, I was, would you think that was okay? It's a very different question, right? It's one thing when it's like, look, that happened. What the, I'm over it, come on, look at, blah, blah, blah, I could even rationalize, look, these things have made me more resilient.

This has given me a chip on my shoulder, this has given me an edge. But when they turn it into, you have a kid. And it's so interesting because just last week I was having dinner with a friend in Malibu. And he opened up to me about something incredibly personal and private that I'd never known, which was that his wife had had a really difficult year. She'd relapsed in her smoking, a whole bunch of other stuff had completely fallen off the rails in their lives, but in particular in her life. We get through the

whole dinner and he tells me everything about the story, and it's just a heartbreaking story. And then he alludes to a fact that was clearly the trigger, which was his wife had been abused very badly by her stepfather had been sexually abused nonstop. It started when she was seven years old. Earlier this year, their daughter turned seven. And it completely triggered this because, and again, if I had heard that before, I would have been like, come on, that sounds like sort of psycho babble nonsense. How is it that seeing your daughter at the same age that you were at when something

happened could do that? Do you see this often? Oh sure. Yeah, absolutely. And to kind of lead up to addressing that, I want to comment on a couple of things. One, you said that the woman who was asking you the questions, okay, she learned, okay, there's this issue and then she learns about anger, right? I would frame that a little differently. I would say that that there's a very skilled clinician that is doing the same thing over the telephone that we might do physically examining a patient, right? And he touched, does it hurt here? Does it hurt there? Right? I mean, if you get where it hurts and we know we're not, even if we're very gentle about it, right? At times the person has a reaction, right? And then you learn like, oh, you hurt

there, right? And that's why you, oh, you hurt there, right? And that's why you reacted that way. And I think that's what she learned. Jesus is it hurt here. Is it hurt here? And then she looks shit. It really hurts there. And you know, it tells us something, right? And what it tells a good mental health clinician is where there's shame and fear, And shame is extremely powerful. And it's technically it's an aroused affect. The word aroused doesn't, it's not purely a sexual word. It often gets used in that way because the idea is something can turn a person on that you didn't choose to have turn you on. But the idea of aroused affect is something that's created in you without your volition. Someone shoves you, you get angry, right?

Someone shoves you really hard, you might get afraid, right? There are things that make a certain, what gets called affect, but locally, a feeling inside of us that we don't have a choice over. And there's an incredible auto-maticity to that. And that's like what you're talking about with, okay, like what is this trauma thing and what is it doing, right? It's not necessarily what happens.

It's what does it make you feel? And my guess is, and again, I don't know, I don't know the person you're talking about, but probably that person is carrying some sense of shame over what happened to her. Because at the age of seven, you know,, there's not the cognitive capacity of deciding, look what's going on to me, happening to me is wrong, the child needs to make sense of it. And often, the child makes sense of it is to decide somehow that it makes sense, or what's happening to them is deserved, or it's their fault, or it's the way it should be.

And that evolves into a sense of shame that the problem here is me. Someone's hurting me in some way, whatever's happening to me doesn't feel good. And it's my fault. And then it creates a sense of shame that does not give a damn about the clock or the calendar or levels of achievement. You have a trillion dollars and 15 PhDs, right? It does not make a difference unless that shame is directly addressed. So that's really the answer, right? Is what has happened to a person and what is it triggering inside of them? The same way there's, there's pretty good literature that talks about, you know, someone

is shocked, right? How much does it hurt? And like, it hurts more if there's no damn reason to have been shot, right? Like, if you try to save somebody and, know, when you get shot, then then people tend to feel less pain because there's a sense that it makes sense in some way, that this bad thing has happened, but something good has come of it, or I was trying to do something good, right? It doesn't seem senseless and sadistic. And that sense of absurdity, the sense of evoked shame,

or a roused affect of shame, the sense of an aroused affect of fear, the sense of absurdity and meaninglessness is what then creates the trauma that stays with someone and kind of like, it's not even like a ghost shadowing. It's like, you know, just imagine someone who like can't stand you that just shadows you all the time and says awful things. And that's essentially what this kind of thing evolves into.

And it's that, that, you know, that raises that triggering that if there's still a sense of shame, and now the daughter is seven years old, you know, what does that make the person feel like, right? The person that identifies with the daughter, they still identify as the hurt child, but now they're supposed to take care of a child who's vulnerable because that child has reached the age at which they were hurt. I mean, it's very, very triggering for reasons that make them good sense. So you've seen this where people's trigger is a child that reaches an age at which some traumatic event occurred. Yes, it's very common because that is a child that reaches an age at which some traumatic event occurred. Yes, it's very common because that is a trigger.

They say, okay, it's my job to make sure that does not happen to them. But I am still in the throes of it. Right. So then, well, I am the traumatized seven-year-old child who is supposed to protect the seven-year-old child. That's terrifying. It's terrifying. And then the part of the brain that is terrified,

it says, look, this absolutely could happen to your child. You can't protect them. And then, you know, the brain doesn't care about the clock and the calendar, so that trauma is very, very, very real to the person, and it's very immediate. It doesn't matter if it was two days ago or if it was 30 years ago. It's just as immediate and we also lose sight of that. And many times I hear people say, well, I couldn't still be bothering me. It was like two months ago, two years ago, 50 years ago. And the answer to that is it does not matter one bit how long ago it was. If it instilled terror, shame, a sense of responsibility for something that wasn't

the person's responsibility, then my guess is we could probably live to be a thousand years old, and that would still be with us. And again, very germane to your practice is that's one of the things that often prevents us from living longer. It's that kind of internal stress that leads not only to suicide and Paris suicide, but also to the kind of strength, it's the kind of stress that contributes to cardiovascular disease, to cancer, to autoimmune problems, to all the things that ultimately, if you look at the population as a whole, that chips away at our health, at our healthy

lifespan, and at our lifespan. I still remember to this day, the very, very first patient we ever collaborated on, which of course, who was such an interesting experience for me, that it's what basically led to you and I being so close at the hip in terms of how many patients we overlap with. But obviously, we won't use her name, but the woman in San Diego that I was taking care of, very interesting case. I think most of my patients are incredibly nice people, but she would certainly be on the short list of the nicest.

It's just a very, very special woman. Yeah. And there were a lot of things that didn't look metabolically right. Frankly, her chief complaint when she came to me was, you know, she just wanted to have more energy. She wanted to feel better. Her father had died prematurely of heart disease.

She wanted to make sure that was not going to be her. And father had died prematurely of heart disease. She wanted to make sure that was not going to be her. And we got to it. We changed her nutrition and we fixed her hypothyroidism and we tweaked a bunch of things and everything on paper looked right, but we couldn't eradicate certain things. There was still a degree of inflammation in her body. There was still a degree of insulin resistance. I probably hadn't seen a patient who could be so compliant with her nutritional plan as she was. And the only one of her meds I couldn't really offer any input on was she was on an SSRI, I think. I don't remember which one. As well buterin if I can remember actually. And, you know, I think this had been prescribed by her family doctor like 10 years earlier or something like that.

But I remember one day thinking about what she talked about when her dad died when she was in medical school. She was a physician. And it cleared me on this particular day, which was like a year after the first time I'd heard this story that I didn't know to use the word trauma, but that was clearly a traumatizing event in her life. And my first thought was actually, I thought of these zucker rats,

right, which I thought of these experiments that occurred because what I couldn't understand was why in the world is this woman who's doing everything right, seemingly have a metabolic rate of a slug, right? It was like she's doing everything by the book, and the only way that we could infer what's going on with her is that her metabolic rate has shut down, because she's not longer hypothyroid, all of the other things have been fixed. And I thought about these Zucker rats,

where they, you know, they sustain certain lesions into parts of the hypothalamus, and they can alter the metabolic rate. And so I floated the idea by you and you said, look, anything is plausible. And to make a long story short, I introduced the patient to you. She came up, she saw you. And over the course of the next six months,

without making any change in the thyroid meds in the nutrition and the exercise, she probably lost 30 pounds. And she looked like a different person. In fact, I remember when I got her Christmas card with her and her family. At first, I thought, I don't know who this is. Why am I getting a Christmas card from a random person? And I mean, what do you remember about that case? Maybe not even the specifics, but just like, were you as surprised by that as I was?

You know, I think the fact that I wasn't is just indicative of, it's not indicative of like some genius that I figured things out that other people haven't. It's just indicative of things that I have witnessed that utterly shocked me at the time, that lead to what I would describe as more than a healthy respect, but an utter reverence for the impact of what the brain can do to the body. And a couple of examples are paralysis of a limb. I mean, I've seen people, seen cases in my training and subsequently taken care of people who do something that they find reprehensible or almost do something that could have been disastrous

and then the limb that they did it with is paralyzed. And now it's like it's 10 years later and the limb hasn't moved in 10 years. I mean, the nerves haven't been severed but they may as well have been those contractures and everything else. I mean, when you see that the brain can like shut off vision, right? The brain can shut off movement to a limb. You know, these are really shocking things. And, and I think that we as a society, like we, we, we just don't appreciate how much impact over all aspects of our functioning, some of the things that torment us inside can have.

So, there was something tormenting this lovely woman that was shutting up metabolism off. And in many ways, I get it. It's a shocking thing. And it would have knocked me off my feet if I hadn't been seen paralyzed limbs before. And things that really kind of told me things that to be honest really made me angry. And I thought, how is it that I consider myself

to be a curious person? I mean, even before psychiatric training, right? And I'm a well-read person. I'm a well-traveled person. I'm interested in other people. I took a broad curriculum and called it like, how is it that I didn't understand these things of what our brain and what does that mean? It means what our brain in the context of trauma, which is about a vote chain fear, thinking about things we're talking about in the patients where we've had these kind of, you know, these kind of experiences,

right? And even in ourselves, think about the impact of shame and fear and what it does to us and people don't tell us that. So then a person feels ashamed, right? That they're eating less and they can't lose weight. They feel ashamed that they're sleeping, but they're not well rested.

They feel ashamed that they wanna be patient with their kids and they can't be as patient as they want. I mean, I could go on and list thousands and thousands of things and what we often don't, again, don't appreciate is where's all that coming from? And is anyone ever asked about it? I'll give you a quick aside that I saw a person in my practice several years,

nearly five years ago or so, very, very intelligent person, very capable, academically accomplished, who was working many, many, many levels, underneath where he could have been operating. You know, $10 an hour job and somebody, you know, who should be running a company, that dramatic. And, you know, I was, I don't know how many people I had seen and talked to this person

before, right? And I asked him a question and you know, we had been talking. So it's not like it came out of the blue, but I asked him, you know, how many times a day do you say something to yourself inside that's some version of like, I suck this response was also as I'm a piece of shit And his answer was like he stopped and says hundreds hundreds of times all the way to the job all the way back in the shower Before he goes when he's back at home with his kids non stop You know that was all trauma-based and it was based upon Be littleing bullying all things that had happened. I mean, you could take a trauma history from this person,

and no one's ever shot him. No one's ever sexually assaulted him, like, oh, there's no trauma. Oh, no, there was gigantic trauma. And if you were saying something to yourself over and over and over again, that is profoundly negative, and that makes you feel vulnerable, ashamed,

inadequate. How are you supposed to be at your best? How does it affect your brain? How does it affect your endocrine system? How does it affect your immune system? How does it affect your vasculature? The answer is dramatically. Then you look at this person who now was aware of substandard role performance and now

he feels worse about himself. And by going after that that we're actually able to Change everything. I mean that the person's life is dramatically different if you look at what he's doing for a living Night, you're like, okay, that's you know, that's something that seems more commensurate and in this person It doesn't represent the endless striving of you who never you know achieve enough, right? In this person It represents something that makes him feel whole that this wasn you know, his ability to be something he could feel proud of to support his family in a way he could feel proud of, it wasn't taken away from him. But if you looked at what was the ideology of that problem, it absolutely wasn't single

digit ages. And it doesn't matter that this was like three or more decades along, right? It was with him hundreds of times a day. And that's why these things don't surprise me. And, you know, I've had an increased awareness over time of my own inner voice, that, you know, I may as well as somebody, you know, behind me all the time. I mean, I've been trying to alter this in some room, someone with your help and a couple of other people around us, you know, it's kind of gotten better and the realization that I carry around with me a voice that tells me how shitty I am for everything that's not utterly perfect for the moment I wake up to the moment I go to sleep

has created a lot of misery in my life and it's created unhealthy situations and you know, times real risk to my well to life and limb for me. So, you know, I'm a huge believer that the reality and the truth that we're living and say that the reality and what we view as truth, that we're living in is often not apparent to anyone around us and ignores it apparent to ourselves. And if we make that apparent, then we can make some decisions about it, which is why that woman was able to lose weight is, because we started talking about like what was actually going on inside of her. And, you know, in a certain person, if you are intensely ashamed and feel inadequate from the moment you wake up to the moment you fall asleep, you probably eat 20 calories a day and you're going to gain weight.

Yeah, that's the part that just blows my mind in her case. The other thing with this stuff that I think it's worth people who are listening understanding and it's so important. I certainly didn't understand it until the past year. I think I wasn't so naive to know that, or I wasn't so, so, so maybe naive is the wrong word. I wasn't so ignorant to think that, look, bad things happen. I got it. But my sort of blind or based mentality was, I can prevent that exact set of things from happening to the next generation to my kids. And of course, the irony of it is you learn that trauma almost always comes out in some orthogonal way. And so it's not necessarily that the child of the alcoholic becomes the alcoholic. In the case of the woman that I was just talking about earlier, who when she saw her daughter turn seven, triggered

all these flashbacks of the sexual abuse, I don't think that I think the probability that that mother is going to go ahead and like sexually abuse her daughter because she was sexually abused by her stepfather. The probability that is is close to zero. That is not how the shame will be transferred to the next generation. It will not be through the same root cause. It will come out in something different. And to me, that's the part of this thing that is so such an epidemic.

You know, Terence Reel, who we've talked about a lot in his book, which I've talked about on other podcasts. One of the most important books I've ever read. I don't want to talk about it. He talks about this. The number of generations it takes for shame to sort of work itself out. And it's like, you know, this happened to the grandfather, this happened to the mother, this happened to the child. And this idea of shame, transference through trauma is, I don't know, I guess like I said, even though I don't do this for a living,

it occupies more and more of my time because I spend more and more of my time thinking about it with the patients that I'm lucky enough to get this close to. And truthfully, there are some of my patients I just don't get close enough to understand this part of their lives. But I want to, because I realize so much of what we do without knowing this becomes quite futile.

Well, absolutely. I mean, if the only thing we're guarding against was the manifestation of something that we recognize, things would be different. And I think the number of generations to get rid of shame without intervention, you know, is either infinite or there's just some, you might as practically infinite. Right. Because why would something like that change, unless it's understood? Now people at times can intuitively understand, I mean, they're things that can intervene. but otherwise you're absolutely right. I mean, it finds a way out, right?

So the person who was sheltered and over controlled as a child, and that led to, say, you know, big problems of rebellion and then something traumatic happens, maybe if they don't understand that they may overcompensate with the sort of freedom and what seems like opportunity for their own kids, but what actually, but what actually puts them inadvertently in danger. Just as the person who was neglected and was in left in situation of danger, may over-control their kids, and then the kids were bailing the same thing happens.

I mean, if we don't understand it, there's a very good chance that it will find a way to get us. And sometimes that's something dramatic. And, you know, I see these cases like, oh my gosh, like this person did the opposite thing, their parent did it, look the same thing happens, right? But a lot of times, you know, I think most human suffering and most bad outcomes, you know,

happen with a fizzle, not a bang. And I think that's part of the really the biggest sadness of it, is the things that we don't know are the person who just languishes, who doesn't have a strong sense of self and is burdened with regret. And that's the story. I mean, there's so much about this that because we don't talk about it, we don't educate ourselves about it, we just let be perpetuated.

And in many ways, I'm not trying to say, this is all easy to address. But some of this, I think, is low-hanging fruit of, look, why are we not talking about these things? Why is it that we enter medical school and if all these overly powerful guys, and we don't think of it, what are we all defending against? Why do we have to be so powerful all the time?

What are we guarding against? Why is it that we feel ashamed if we're not powerful? If we're not, you know what I mean, if we're not perfect, if we're not the best, right? Why is it? And I'm not saying, gee, let's have some soft way of going about life and then people aren't driven to achieve things, but it's a lot of it is based on this lie that like, what doesn't kill us makes us stronger. Okay, that is a lie. Sometimes something doesn't kill us and makes us stronger. You know, we can get an infection.

It doesn't kill us. We develop antibodies, right? It can happen on a biological level. It can happen with a life tribulation, but my experience in my own life and in the people around me that I take care of, or my friends, family, patients, that like the humans in my life, is that bad things that don't kill us off to make us weaker. They hurt us. If we don't acknowledge that, what is this thing done to me?

We put it onto the surface and we soldier forward. And for a lot of people, you know, what does that mean? I mean, it does mean languishing. And oftentimes for people who maybe are blessed with more drive and perseverance, sure, it means we drive ourselves to achievement, but amidst all that achievement, we remain miserable because the hurt part of us is like still what we're living in every moment, every moment, most of the time we're living in that hurt person, but that hurt person is festooned in a way that doesn't look like that. And if you think about very powerful things in culture, you know, the wizard of Oz,

you know, like such a cultural touchstone across generations, even the stupehamper is new clothes. I mean, we're infatuated with things looking some way, but being another way, things looking strong and powerful, but being weak and vulnerable. And part of our infatuation with that is it can take the fear out of some of the things that scare us, but I think an even bigger part of that is that we often identify with that. We identify with, you know, festooning ourselves, look how

great I am. And like, you know, really, I'm not festooned in anything, right? I mean, there's like a, there's a pathetic nakedness to some of it, right? But, but we sort of posture that way, right? And we posture that way in order to shore ourselves up. And if I see a commonality between like how you and I practice medicine and how the vast majority of I think good doctors practice medicine is it's with not hiding vulnerability. I do not feel in any way shape or form healthier than the vast majority of my patients. I mean some people yes, I've had a bad head injury, I have schizophrenia, okay.

I don't feel any better, necessarily healthier to them a lot of the time, but there's an identified problem that we wanna address and treat that can let the person feel a greater sense of wholeness. Okay, that's valid, but most of the people that I encounter are just struggling the same way that I am.

And, you know, there really is no difference except that person may do something, maybe someday I need an architect, a financial manager, a lawyer, whatever it is that they're doing, but we're no different. It just happens to be like, okay, this thing I do brings them to come to me for help about this certain thing. But we're all people are trying to make our way

and survive in the world. And often some of the people who I feel are most put together are not the people that you might think, right? They're the people who, if you look at their achievements, you know, you're not going to be wowed or buy it necessarily. But they're people who have a greater sense of wholeness. They're people who have maybe spent more time and effort on themselves. And again, this is not an anti-ambition agenda that I have here, but what I absolutely am

saying is that very, very high levels of achievement are a marker in my brain for suspicion that this person is defending against something. And that's the reason why I thought that. You should go to the bridge. It's the reason why trauma therapy that you should go to the bridge. It's the reason why trauma Therapy is part of my psychotherapy. It's the reason why at some point I should go to the bridge too, right? I mean this you know the nickname for that place is you That person who told me I send a bunch of people there and no one tells me this and then you do I do I know it has two nicknames

Camp misery and the crying fact. The kids only the crying factor. The crying factor. And it points out that making ourselves healthier often is difficult. It does involve misery. It involves tears and exposure of things we're ashamed of. And of all the places that I have sent people in, you know, at this point in almost two decade career, you know, I think that they are the most effective or among the most effective of places. And I think part of it is because they don't shy away from that.

I remember something you said to me because you suggested, look, there are two or three places where I think you could go. Here's why I think the bridge is the best for you. And one of the reasons was, oh, I'm almost embarrassed to admit to people, doesn't mean people what I asked you, but I said, Paul, when I looked at these other places, the bridge seems unique in that the socioeconomics of it look very different from where I've come from. Meaning, I'm not going to be there with other people who have gone to medical school or gone to law school or whatever, will I have enough in common with the other people there? And you said, that's exactly why I think

you should go there. And I didn't understand that. So I go there. And of course, the first rule is everybody has a roommate. Well, I don't want to go to him roommate. I'm 45 years old. I've passed that course, right? I did that. I did summer camp already. I don't want to go to him roommate. I'm 45 years old. I passed that course, right? I did that.

I did summer camp already. I don't want to roommate. So I have my assistant call over and say, hey, we'll pay extra, but he needs a solo room to which they sort of said, thanks for telling us how to do our job. That ain't the way it works. He gets a roommate.

Again, everything that they did that I thought was pure torture turned out to be perfect. There was exactly what you said. I had to be around people who I could relate to intellectually, who I couldn't relate to intellectually, who I had a similar education to, to whom I did not. But in the end, what I realized was, we are all the same. And I guess that is such a banal, glib idiotic statement, but it's fucking true. We are all the same. And I guess that is such a banal, glib idiotic statement, but it's fucking true. We are all the same.

My roommate, I swear for the first three days, I thought, I don't have one thing in common with this guy, I loved him out of the gate. I mean, he was just an amazing guy. But I was like, we don't have anything in common. And that's fine. I mean, I didn't make me like him any less. But two weeks later, I realized,

oh, actually, we have more in common than I would have ever dreamed we have. The reason we look like we have nothing in common is perhaps some innate wiring, perhaps some stochastic events, but in the end we took very different divergent paths. You know, mine led me to college, his did not. My weakness has led me in a different area than his did.

One of the things that I found most powerful and I'm bringing this back to a point you made earlier was in addition to 13 hours of camp misery every day, seven days a week. You get to go to a 12-step meeting every single night. You get to pick what it is. So they're not gonna tell you which one you're going to, but you're either going to AA or Alonon or Coda or NA or SA or SLA, you're going, I think you got one night off a week. I think Sunday night you got spared the meeting. And I remember thinking the first few times, like, I'm so tired.

I'm just so emotionally exhausted that, you know, it's 7 p.m. or 8 p.m. all I want to do is go lay on my shitty bunk bed and sleep. But they're like, nope, you know, it's 7 p.m. or 8 p.m. all I want to do is go lay on my shitty bunk bed and sleep. But they're like, nope, you got to go. And you're a guy, by the way, who could work? What, how many hours? Oh, yeah, yeah, yeah. Constantly as a surgical resident, right? Yeah, this was a different level of fatigue. By eating. So the fact that you're that exhausted speaks to like, what's going on, the magnitude

of what's going on inside of you. I find that to be like, really fascinating and a great proof of concept. Yeah, this, in many ways, hurt more than swimming in the Catalina channel every day. Wow, okay, that's insane, something, right? So, but what I realized when it was all said and done, because I ended up being quite surprised at how much I really got out of being in these

12 step meetings. And I wasn't a participant. Every meeting I went to was an open meeting. I never once spoke, never once. But I was so moved by the vulnerability of these people. Now again, part of that might be an artifact of the fact that we were two hours outside of the nearest civilization. I mean, we're an hour outside of Bowling Green Kentucky. Like, we were in a place that I don't even, I wouldn't know how to find on a map if my life depended on it. But I couldn't believe the vulnerability in these meetings. And I think in many ways that isn't antidote to shame. It is the beginning of it. And fast forward five months I'm back. I'm in, I'm back into my life. And obviously much of my life has changed a result of this, but look, we still struggled.

And we're still always thinking about these things. And I remember my therapist in San Diego said something that I thought was so profound. She goes, you know, Peter, part of the problem with you is you're always the smartest guy in the room. Now, she didn't, she was sort of mocking me. She wasn't like actually telling me I was the smartest guy in the room. She's like, you basically are always the one on point. You're the one talking. You're the one giving the advice. You're the one who everyone's

looking to for the answer. And the problem with that is, like, you never get the chance to listen and not say a word and not have anybody even give a shit that you're in the room. And I was like, you know, that's the key. That's the thing I miss about the 12 step meeting was nobody gave a shit that I was in the room. And even if I was and I you know, that's the key. That's the thing I miss about the 12-step meeting was, nobody gave a shit that I was in the room. And even if I was and I said, yeah, my name is Peter, it's like, great, thanks for being here, Peter.

You were no better, no worse than anybody else in this room. And so in many ways, I feel like, and again, I don't think it has to be the 12-step stuff. I know people are gonna listen to this and say, oh, 12-steps, a bunch of nonsense. What works for you works for you, but the point is there is really something to be said for that type of vulnerability in a group

where nothing else matters. It doesn't matter how much money you have, it doesn't matter how many degrees you have, it doesn't matter what you've done. I mean, none of those has mattered. Of course, the next place where that became the most riveting to me was on this prison visit that I went to, which we've talked about as well.

And again, just another great example of how, in that moment, in a moment of redemption, all it matters is where you are in that moment. And I just find that way. Again, as I'm sitting here and listening to all of the things you're saying, of course, my mind is immediately going to, okay, what can we do? What can we do? What can we do?

What can we do? What can someone listening to this do? What can someone listening to this, who's identifying with this saying, you know what, like maybe that thing that happened to me when I was 10 or maybe this behavior that I have that's on the surface reasonable, but underneath the surface is maladaptive. Maybe that needs to be revisited. And again, if the answer is they need to seek therapy fine, but what else can people do? I think that it's so important to try and take stock of how are we trying to separate ourselves from other people. I mean, think about the things you're saying. It's it's very interesting. And people listening to this who know you will know that this is true.. And people listening to this who know you, we'll know that this is true.

And for the people who don't know you, please I would ask, take my word for this. I mean, you are the least entitled condescending human being, right? I mean, you do not feel superior to other people. I don't think I've seen one with of that in the two decades. I've known you. So why is it that you want a private room and that you want to be different?

It's a reflex. And the reflex is like, I've got to stand out in some way because that's what allows me not to feel superior, but to not feel ashamed. And that's often what is driving us. And it drives good things, right? I mean, your expertise and often being the focus in the room because you have you know, things to say to offer is like, these are good things, right? I mean your expertise and often being the focus in the room because you have, you know, things to say to offer is like, these are good things, but they're also driven by the need to separate ourselves. And, you know, we, it's not that both of those sides of the coin have to come together, but if we're not aware, they do come together. And then you're doing something by reflex that is the exact opposite of what you need. What you need is to be part of the humanity around you, right?

What you need is to relate to people. What you need is to feel that, my God, I'm a human who suffers from human things like these people around me, some of whom are nothing like me, some of whom maybe like me, but like none of that matters. Where all people and our suffering is shared. That takes away the unique stigma other things that you are suffering from. But your reflex as mine has been and as is the case in many people who are sort of driven to differentiate themselves is to differentiate yourself so that you guarantee loneliness. And you know, that's what people, I think really should try and be aware of, is when are we differentiating ourselves from the world around us because

we are trying to escape from something but in doing so, we isolate ourselves. And we don't, we don't get a chance to just be human. We don't get a chance to just be human. We don't get a chance to just be people. Like, you know, the people who are there at the bridge with you had trauma and suffering and they needed to express emotions and they needed to cry and they needed to get angry and you did too, right? And I have to and so many people need that to heal, but we work so hard to separate ourselves from that.

And that's what I think, you know, if there's one thing like some persons can be attuned to, is how much are you separating yourself from the humanity around you? You know, groups of people, when people have agendas or angry can feel threatening and intimidating, but there are many places that people gather in order to feel some sense of openness and shared humanity.

And that's really what we're all seeking. You know, I know you know this, but seven, eight years ago, and I had a clinic that myself and my practice partner built to be know, to be relatively sizable and we were doing a lot of individualized treatment and we were running groups and the groups we were running were around addiction. And we were absolutely adamant that we did not stratify people by what they were addicted to. So gambling, cutting, sex, cocaine doesn't matter. Nor did we stratify people by age, socioeconomic status, and it was a pressure to do that. Because certain other people who had more resources, like wanted that,

not realizing that what they were asking for was the very thing that was going to stand in the way of their ability to get help. That's, you told me this exact story when I called you up to say, wait a minute, I don't think the bridge is the place for me. Yeah. And I should be going to this place or that place. And you said, no, what you're missing is you absolutely need to be around people who on the surface, you think you're different from to realize that you're not.

Right. And it's an advantage that people have if they're at a stage of life or for whatever reason, they're not in a socioeconomic class that allows them to differentiate because and they don't strive for something that stands in their way. And you know, and I think back on that venture, which over about five years, you know, my partner and I, and you know, we had, I don't know, 30 people or so, in some way, shape or form, we're working for us by the end. We all, like, really, could slave to way to make that place as good as it could be.

And when I think back on it, you know, I think the proudest moment, people have asked me, this is like, oh, that was so difficult. And so some people who know me and kind of know what we struggled through. And like, some of the people ask what do you feel good about, right? And the same image comes to mind is I remember, you know, a young woman who I've probably said, I think she was 19 who really had struggled and was trying to find her way. And it'd been on the streets and, you know, to the outward look of things, you know, as piercings and tattoos and all the kind of things that kind of mark her attempts to differentiate herself to say,

okay, stay away from me in a way that she was using to separate herself. And she had made so much progress, so much progress in embracing who she was and not feeling ashamed of who she was and not feeling responsible for things that happened to her that she had no control over. And I remember her, I walked by a kind of late one day after groups had let out and she was having this like really intense conversation with the neurosurgeon. And it was so clear that she was teaching him. I got a lot of things. And you know, and he was in sort of wrapped attention. And it's a marker for me of like our shared humanness is like, you know, if you look at him and you look at her, you say, okay, the things they've achieved.

Clearly, he's the authority. He's got a CV, a half a, you know, half a mile long, right? And, you know, this woman has been struggling to stay off the streets. She had done more work on herself, so she had a lot to teach him. And I have found that again, it sounds right. But the things that I have learned through the course of my work, so much of them have just come from people who have been through such difficulties and have learned things about themselves that I hadn't yet learned, not at all tied to any metric other than that.

And I think that's part of the secret of it. And we don't do these things anymore. We don't have places where people can come and even get some mental health education, some idea of like what else then in terms of trauma. Like we don't as a society acknowledge this. So then it becomes some like shocking rarity when somebody finds their way to it. And I just, I'm astounded by that, that we should be setting a roadmap with really gigantic arrows for all of us. But, you know, person has to stumble upon it or

come across it inadvertently. In many ways, I think I'll forever be grateful. I mean, forever be grateful to you for making this happen because I guess some people just can't they need a greater degree of immersion to finally break down. I think I could have spent two hours a week in therapy for the rest of my life and never, never come close to what finally takes place when you're doing 13 hours a day plus 12 step meetings. And not only that, it's like every meal, you're sitting there with the same group of people. We only got coffee once a day.

Seven a.m. was coffee time, and it was like I would get up at four and work out, and then I'd be waiting to have my coffee at seven, and there were like six of us that showed up for coffee every morning, and the other thing about this place that was so amazing, which really ties into what you're saying, is everyone who works there, obviously not just the counselors and the therapists, but the kitchen staff, the custodial staff, the people that worked at the barn where we did equine therapy, every one of them had themselves been a client there.

Wow. I didn't know that. That's amazing. Unbelievable shared experience. Like, we are all the same at this place. Wow. And isn't there comfort in that, right? Absolutely. How can you be some exception who deserves shame for being something less than perfect

when you fully apprehend that reality? Can't be, right? You know, you said something a moment ago that made me think of one of my favorite talks. So, you know, you know that I'm the biggest fan of David Foster Wallace, this person who I've just, I've just always been kind of so amazed by his insight. I just, you know, here's a guy who was not a trained

psychiatrist, he's a writer. And yet, his insights into humanity go beyond almost anything I think. You couldn't learn this stuff in a textbook. I've been asked before if you could bring anybody back from the dead, of recent era, who would it be? I think it would be him. If I could go back in time and spend a day with anybody, it would probably be David Foster

Wallace. He has a very famous commencement speech from 2005 that he delivered at Kenyon College, titled Vises Water. And in it, he talks about the fact that we're, I think he, the way he describes it is, there's no such thing as atheism. We are all worshiping some God. Do you worship money? Power, your body, your physical allure. And he almost makes the case that at least if you pick a God to worship, the harm to you might be less. Because if it is money you worship, you'll never have enough. If it's power you worship, you'll never feel strong enough.

If it's intellect that you worship, you'll never feel strong enough. If it's intellect that you worship, you'll always feel like a fraud. And I remember listening to this for the very first time, which was many years ago in thinking, yeah, I get that. Like, I really get that. Like, I know, I'm not alone, but I think a lot of people who place their self worth and their intellect, you think, what if people find out I'm not that smart? Like I'm just a fraud. And you know, it's, again, it's just, it just speaks to this entire nature of humanity.

And of course, the tragedy in the case of David Foster Wallace is that he ends up taking his own life by suicide three years after he gave that talk. Now totally unrelated, I want to play something for you. So, I was actually just listening to this today. I hadn't come across this before, but this is an interview with David Foster Wallace and Terry Gross from NPR. I believe it was 97. So, it was like a year or two after Infinite Just came out.

So, I want to play this for you if I can cue it up on my phone here. Because I thought of you as soon as I heard this, right? Okay, here we go. You know, I really like the way you talk. You write about a pleasure and how difficult it can be to really achieve. You write about pleasure in the infinite gest, your latest novel.

And I'm thinking, you know, one of the things relating to that, an Infinite Just, one of the characters finds that marijuana is no longer a pleasurable experience, it just makes them terribly self-conscious and therefore anxious. And I'm wondering what happens to you when you do something that's supposed to give you pleasure, and that just makes you uncomfortable or anxious? Boy, I'm not really even sure how to respond to that. Look, a lot of the impetus for writing, if in a just,

was just the fact that I was about 30, and I had a lot of friends who were about 30, and we'd all been grotesquely overeducated and privileged our whole lives, and had better health care and more money than our parents did, and we were all extraordinarily sad. I think it has something to do with being raised in an era when really the ultimate value seems to be, I mean, a successful life is, let's see, you make a lot of money and you

have a really attractive spouse or you get infamous or famous in some way so that it's a life where you basically experience as much pleasure as possible, which ends up being sort of empty and locality, that the reason I don't like talking about it discursively is it sounds very banal and cliche, when you say it out loud that way. Believe it or not, this came as something of an epiphany

to us at around age 30, sitting around talking about why on earth we were so miserable when we've been so lucky. Well, when did you realize that all the benefits you had in an educated middle class life weren't bringing you happiness? Well, I guess it sort of depends on what you mean by happiness. I mean, it's not like we were walking around fingering razor blades or anything like that, but it just sort of seems as if we sort of knew how happy our parents were. And we

would compare our lives with our parents and see that at least on the surface, we're according to the criteria that the culture lays down for a successful happy life. We were actually doing better than a lot of them were. And so why on earth were we so miserable? I don't think, you know, I don't mean to suggest that it was, you know, I don't mean to suggest that it was, you know, a state of constant clinical depression or that we all felt

that we were supposed to be blissfully happy all the time. There was just, I have a very weird and amateur sense that an enormous part of like my generation and the generation right after mine is just an extremely sad sort of lost generation, which when you think about the material, comforts, and the political freedoms that we enjoy is just strange.

I could listen to interviews with David, well, indefinitely, but it's interesting that I came across that today for the first time, again, I don't know how I missed it. Oh, wow, today. Today, just literally today, and I knew that we were gonna be speaking this evening and I thought, you know, I'm gonna put Paul on the spot

and play that forum and ask him not just to explain that, but even more broadly, what the heck is going on, right? Why? I mean, let's take a step back. It would seem to me that suicide is the least likely cause of demise for our species, just given our evolution. I mean, it seems to me that we are wired to survive. So in other words, and again, I'm certainly not being critical of suicide.

I have nothing but empathy for obviously anyone who can commit suicide. It strikes me as the saddest thing ever. But I don't understand it. Like I don't I don't understand how it can be so prevalent when we must be so wired To not want it when we must be so wired to want to survive and it I remember Very recently I remember having this thought probably in the wake of the you know these high-profile suicides Which you know I remember when Robin Williams killed himself the same sort of thoughts go through my mind Which is did our ancestors do this? Is suicide a symptom of our civilization?

Is what David Foster Wallace is talking about here, even comparing ourselves to one generation ago? Are we less happy or do we just have greater expectations? And those expectations being unmet is what makes us feel unhappier. Again, it's so complicated and I want to start off by saying, by no means do I attest to any expertise or a right to offer an opinion that's more valuable than anyone else's. But the thoughts that occurred to be is we're wired to survive as long as we see meaning in survival And I am not here trying to glorify struggle

But there is something around struggle that gives meaning You know people who struggle to survive in war zones You know people who see meaning in survival they see meaning in what they're fighting for. You know, Dr. Frankl writing an immense... Of course. ...for meaning, right? If you don't have meaning, then why would you struggle to survive? And it's not a lengthy extrapolation of that to say, if you don't have meaning, why are you interested in surviving?

Have you read Tribe by Sebastian Younger? I have not. I probably should and I've been told several times I should. I just haven't gotten to it yet, but I understand I think something is going on. I think this is sort of part of what he's getting at. Yeah, that we, like, okay, for example, I really, I mean, it's interesting, right, given what I do for a living, that like, I don't know how I value myself. I don't know how to value myself and whether I'm succeeding or not. I mean, is that what my family of origin thinks of me, how much time I spend with

them, I've certainly ranged far afield and left the place I grew up in order to achieve things and do things. I should have be proud of that that. If I have I, you know, not been a good friend or family member to the people I grew up with, do I value myself by what other people think of me, how many patients I feel I can help, the health of my relationship with the people I love as adults, the kind of parent I am, kind of husband I am, how much money I have, how many people want me to offer some expert opinion on something. It's like, I have no idea, I have no idea whatsoever. And it occurs to me sometimes that all those ancestors of mine really knew how to value

themselves, like are the sheep safe? Is there a roof over our heads? And again, I am not glorifying the lack of opportunity, you know, the lack of like a basic medical care right in generations past. But there is something very, very concrete about that. And when people go through struggle, when we often most worry about them is when the struggle is over, when people feel like, I made it through that, you know, whatever that was, maybe that was chemotherapy.

Maybe that was the death of someone close to them. Maybe it was a particularly trying time at home or in their career. You know, people will persevere when they see meaning in their struggle, but when there's not a struggle, the struggle is over or we're not particularly struggling for something what does, how do you value yourself? And I think often we don't even know enough

to answer the question. I mean, like you and I have never sat down and talked about this. We spend a lot of time together. We've been close for two decades. Like why don't we not talk about this? In part because we don't understand how meaningful it is, right?

So we value ourselves by persevering. But that's endless, right? I mean, as you said, there's always more of things to have. So at a certain point, that can seem very, very hollow. And I think that in many ways, that's the disease of the modern civilization. Me, even when we grew up the time of the Cold War, I mean, I grew up with this very clear idea. And I get that, you know, it was a simplistic idea, right? Look, the West is good. And, you know, we fight for democracy and, you know, the Soviets are bad. And look, I get that this is not the case. I mean, I spent time in Russia and in Eastern Europe.

And like, I get like, the people are people, but it was an easy, it was an easier algorithm to grow up in. And it instilled faith in America and faith in what we stood for. And as we get older and wiser, we all learn about the hypocrisy of life and the truths of life and you know, learning of, you know, I remember learning about like things that America had done in central America, right? And, you know, and feeling a sense of like, oh my god, like we are not this force of good. And it doesn't mean that we were a force of evil. It means that the situation was far more complicated, but it provided a heuristic. And even that was something that kind of made sense. I mean, I can remember the Olympics coming around and like feeling this sense of, okay,

like it's, we're going to beat the East Germans and the Russian. Then, you know, there was just a sense of dichotomization, which is why people who want to control other people know to make struggle, right? You make an enemy. So this is all a double-edged sword, and you can make meaning in ways that is not valid, right? Those people are bad.

Let's go kill them. That's a way of making meaning for people. It's not an honest or moral way. But what I'm trying to point out is that we see value to our struggle if we see meaning. And I think that for a long time, even as people got wisdom and greater knowledge of things like hypocrisy and the truth of the world, I think we still saw greater meaning. And I'm not so sure that we do as much now. I think that things are much more nebulous and then it's hard to get around the idea of, well, do I really matter?

What am I doing? What am I standing for? What's really the difference? And I just think, look, that can happen at any time and probably it did happen in a back. When everybody lived in caves, but I think we're much, much more susceptible to it because we don't have some sense of community. We don't have a sense of community. I mean, it's interesting, right? People have written about why do human beings, on were so focused on survival, right? There's a lot of people that will spontaneously risk their life for somebody else. Jump into the river, right? Try and rescue somebody. Why do we do that? And the answer is because in that moment, we see very clearly

defined a very lucid meaning to our actions. And I think that that's very, very profound. And I think it's the opposite. I see that as the opposite of suicide, which is, which I mean, it can happen for a lot of reasons. I'd be going to be very depressed. And the delusions of lack of worth, I mean, again, it's very complicated.

And I'm not trying to trivialize it. But I think a lot of what promotes suicide is the absence of meaning, which I see as the opposite of someone who's taking good care of themselves and they want to stay alive very much so, but will risk their life to help someone else. That's a focus of meaning that there's a compelling meaning right now.

Right. What parent wouldn't jump in front of a car to push their child out of the way? Right, and a lot of those parents who want to be there for their child would jump in a river for someone else. Like as they see a child, so you know, it's that just capturing of the attention. Like, this is meaningful. Look at this. I will make a difference now. Right, and I'm willing to take a chance to do that. And I think it's very, very different than how a lot of people feel. I think also socioeconomic demographics.

I mean, if you think that I don't know what the exact numbers are, but what percentage of people in this country, I was sort of reading the reports around like a $500 unexpected bill, right? And like people can't survive that, right? Like they're not gonna get medical care, they're not gonna, you know, service the car and then they can't get to work

or they're not gonna, you know, they can't live a life that we would consider acceptable, you know, with an unexpected, in the grand scheme of things, otherwise surmountable amount of money that's needed. And, you know, I think that's a very, very hard way to live that, you know, a lot of what we're talking about is, Foster Wallace was talking about, of like, well, we have so much opportunity to be don't have to struggle, right? But if you are struggling to put food on the table and, you know, you know, that if somebody

needs to go to the emergency room, how the hell are you going to get enough food, that's a struggle. It's very hard to see meaning it. That's a struggle that seems like denigration. I mean, it's, it's, it's, you're gonna struggle. Whereas it's different, our ancestors, if they had to struggle through a famine or drought, I mean, it was just, that was just, that was the gods, right? That was nature. That was the season, and they were in it together. Right, and it's not like you were struggling because of the drought, but your neighbor was rolling around in a whatever the equivalent of the Ferrari would be.

Right, and I think even it's so, it's so in a way baffling, right, that, look, I hate the thought that how many people are there, that five-inch-yard medical bone, they can't put food on the table. Yet, I'm fortunate to live in relative plenty compared to that, but I don't know how to bridge that gap. There's not a sense of community, and sure, like, we can donate, and we can do things for free, and all of this, but like, we don't have a sense of, what does that mean?

And how do we change that? And how do we make that better? And my sense is that I actually feel quite insecure. Do I have enough, if my kids need something, right? Do I have enough if, you know, things really go south and it becomes unsafe to live here. I have a sense of vulnerability. What does someone feel like who has the same sense of conscientiousness towards the people that they love through $500 can sink? So, I'm not trying to make specific points about that,

but really to point out what I view as just a tremendous sense of isolation, and it's not a disease of plenty. I mean, I think it's a disease that affects people who have enough, and that affects people who don't have enough even worse. And that lack of shared sense of community, a lack of being in it together, you know, it may sound hokey, but through most of life, that's how people lived. I mean, unfortunately, Paul, everything you just said doesn't really seem to offer a foreseeable remedy to this. And if today we're seeing 30% more suicide or thereabouts, then we were a couple of decades

ago. Is there anything on the horizon that's going to curb that trend, or is suicide going to become an increasingly greater part of our humanity? And perhaps, worse yet, for every person who actually kills themselves, what if there's nine people who are in that category we described earlier is basically functionally dead. And then you think of the effect of the... Exactly. What's the triple-down effect of that on the next generation? I do think that there are ways to make this better, and I feel strongly and passionately about them. You and I have talked about some of them, and I'm fortunate to have dialogues with people who can really kind of help make a difference in this way. Again, do I know that it's the right way? No, I don't, but it's the best I can think of,

which is, you know, it's a simplification, right? We don't have places where people can come together and have shared experience and have a sense of community. Like, what about places where there are people to facilitate human connection and education, even about the basics of what's going on inside of people. And there's a couple comfortable couches and a part of coffee. These are not expensive things.

I mean, you think about it in this country, what things cost? Go get an X-rays, $700, right? I mean, we've built up so much cost around things, so much liability, so much that prevents really basic simple things from happening. And we've lost the basics of community support. I mean, there was an era before you and I were practicing medicine, certainly before I was before I was a psychiatrist, right? Where there were community support centers and they were

publicly funded and it didn't cost very much money in the grand scheme of things and there were places where people who are pretty mentally ill could go for support. Not only do we not have places like that for you and me and the other people who are front managing to function, we don't even have those places for people who are really mentally ill. So we don't provide anitis in the community for the basics of what I would call psycho education and for the ability to do that in a way that

really links human beings and looks at what their needs are. You know, how many times have I seen where a person who, if they overdose or they slit their wrists, right, that the world will pay a million dollars for their intensive care units, but what we will not do is buy them the $300 alternator that could fix the car that allows them to not have to go back to the abusive household situation that leads to the

suicide attempt that that society pays a million dollars for. Like a lot of what we do is utterly absurd as a society. It's not even cost-efficient. If you took out care and concern for human beings and said, look, let's factor that out, it's absurd. You know, it's like, you know, you'll throw away $10,000 to get a dollar. And that's how we operate as a society. And I think that if we're going

to survive our own progress, you know, as a species or certainly in this country, we're going to do things that are around mutuality and community support. And we're going to do things where people who have something can help people who don't. And maybe that's $300 to buy an alternator. You know, maybe it's not that. Maybe it's somebody who doesn't have the education or resources that you or I might have who share some wisdom that they've learned. I mean, it's not just all the people who have do things for the people who haven't.

I mean, we all have and we all don't have. And I'm not trying to trivialize the struggles of people who can't put food on the table like that's what we need to work so that that's not the case. And it's actually not that hard to do. But at the same time, we need to recognize that that people that some of the things that we've done through drive to separate us make us lonely and isolate us. And I think you and I have as many emotional needs and as many struggles that can be sued by other people as somebody does who might identify as underprivileged or ill,

like I said, we're all in it together. And but we work so damn hard to separate ourselves. And you end up with maybe not everybody, but most people feeling some sense of loneliness and isolation. Hmm. It's, uh, there's no easy antidote. You and I have spoken a lot about the idea of creating a tribe. We think about the seven of us from medical school, and it was like, we had this fantasy, like,

what if we all could get jobs, not only in the same city, but like we could all live in the same block and We could all just sort of be one family the kids could go between the homes interchangeably meals were consumed interchangeably like it was just You know creating a tribe in the way that it would have existed 10,000 years ago. But we still put our shirts and ties on in the morning and go to work. But there's this closeness that seems so distant right now. I mean, you and I are so fortunate because of the geography in which we work that at least a few times a month we get to have a meal together. But that is harder and harder to do with friends.

And I suspect that there are many people who go months, if not years, without really getting to do that, because it's just too busy. There's just too much to do that's mission critical. Right. And there again is the automaticity of a value system that, you know, I struggle very much with how many people do I care about who've been really important in my life and I think and I in theirs that we exchange to emails a year. I mean why? Why do I not take two weeks every three months and go around and see people I care about? Why don't we do that? And I think again I think I do think that all paths,

I mean, maybe not all paths, but I think the majority of these paths lead back to trauma, that there's a way in which I feel too insecure to do that. I'll step away from my work, and maybe it won't be as good at my work, or opportunities will pass me by, and I'll earn less, and all these things that actually make no sense whatsoever, but it's not as if I can stop them from driving me. And I want to sound futile about that. I mean, I think like there are things that we can do, right? And I think like you and I do some things that we might not have done even a couple of years ago, right?

But do I think that we do enough of it? No, I don't. And you think about those other people that we were in school with and care very much about and then think about people who weren't in that group that we know well and knew well and care very much about how much do we really see of them? Almost nothing. And it's a strange thing to have so much automaticity to our value system. And we might think, well, I never decided, I don't value that, and I value another day of work overseeing those people.

Okay, I never actually put words to it, but I've decided it, right? Because I act in accordance with that decision. And yes, I'd like to be healthier about those things. But I think the answer is as a community that we start teaching ourselves and teaching people how to be healthier about those things because you can still be very good at what you do. Very successful move society ahead. All these things that we want to do if we achieve and have a better sense of balance and mutuality, which is why a lot of these fantasies. And that's

what kids say in kindergarten. So they're best friends. We're going to live next door to one another, right? Okay, we're still saying that medical school left here. We're freaking 45 year old dudes. And we still say the same thing. Right. Because I think we still have the same needs within us. And we still have the same fears of loneliness and isolation and struggle and isolation. So the fantasy is still there. I think because there's meaning to the fantasy. It's a recurrent fantasy in a lot of people that tells us something about our desperate sense of isolation. And I have no basis to back this up,

and it probably is politically incorrect to say this, but I actually don't give a shit. You can be married, you can have the perfect spouse, you can have all that stuff going on, but I say this only being able to speak from my vantage point, which is as a male, I think that there are certain needs that can't be met by your spouse. There are certain needs that like, and again, I think my wife doesn't even like hearing that.

Like she'd like to believe, understandably, that every problem I have emotionally can be rectified by discussing it with her. But I do think there's something different that I think there's a maybe even a degree of vulnerability that exists outside of that relationship and or maybe even there's just something gender specific like a guy needs to be with a guy sometimes, a girl needs to be with a girl sometimes as far as as truly talking about some of these things. And I think that for many people, as they get older, as they have families,

as they have kids, as they have careers, they lose sight with those other people, meaning the woman loses touch with her female friends, who I think can offer her something that her husband cannot, even if they're the most well-adjusted couple. And similarly, I mean, I can't tell you the premium I place and the time I get to spend with my male friends.

And it's hard because as you said, it often comes at the expensive time with your family. I mean, every minute I'm here in New York right now, you and I are here, we're not with our families. Right. I mean, I think that that is a human problem. I mean, I think that we see it through our own lens, right? But I don't think it's based upon gender, social, economic, class, sexual orientation.

I mean, I think it's a human problem that there's a fallacy that says that we're supposed to enter a committed relationship, which already think about what their people who, you know, might not be able to do that, right? Might not want to do this. Or already saying the factor that that's not okay. So I think how many people were invalidating already. Then we say, okay, even if you do that, we're going to put so much pressure to be everything to one another that we guarantee

almost a sense of a failure or of inadequacy. Why should your lovely, wonderful wife think that she can be everything to you? That's just not how humans work, but somehow society is told her that, and then it engenders some negative feeling because both you and she, being healthy people, need a broader set of connections. But we're taught to kind of hunker down, and that's what we're supposed to do. And then when we're getting away and we're doing these things with our friends, that there's something about that that seems kind of trivialized because we don't live in communities where, and then look, think about it.

I haven't thought about this when we think about in medical school when we were kind of living in a community and we did spend time like if we were friends, then I spent time with Jill and you spent time with Brooke. We were in a community, so there was more of a sense of community. And now we don't have that as much. Like that's not the way it's supposed to be in a sense. And then it engenders these unrealistic expectations of self and others. And the question I would most ask about that, I don't know, the answer to like, why don't we continue to live in a communal way? And I think that that's some of what communities offer people,

right? Communities that are based around religion or based around shared interests, those can be very, very good things for people. Of course, like anything else, the other side of that sort is they can be used to create cults. And now about like affiliate, right?

And people are desperate to affiliate. So I think if there isn't health and balance, then, you know, we see more than negative side of things. We don't have enough community affiliation. So, there are a lot of people who get caught up in culture, cult like things, you know, more than we would, more than we necessarily know on the surface, because there are a lot of things like that that don't get

defined as such or you don't get, you know, acknowledged as such. They just don't come to attention. But there's a lot of things like that that don't get defined as such or you don't get, you know, acknowledged as such. They just don't come to attention, but there's a desperation for connection and for a multiplicity of connection and a variety of connection. And we live in a way often that really makes no sense. There's no reason why should one person be everything to one other person. You know, life is more complicated and more interesting and richer than that. Are there any books that you would recommend people read? I mean, I have my sort of list of go-to books that I've suggested to people over time.

I certainly hope that anybody who's listening to this that thinks that some trauma in their life has continued to sort of yield its grip around their neck, will look into some of these trauma-based treatment facilities, and ultimately seek out therapists who themselves are well-versed in trauma-based therapy. Again, you don't have to go to an inpatient place to start, but I've since learned the importance of trying to vet therapists to find out who truly understands this. But what other resources, whether it be books or facilities or anything, I mean, what kind of things can we leave people with to think about as they begin to navigate their own path?

I mean, like I said, I suspect there's going to be some people for whom this episode scratches a scab a little bit, creates a little bit of bleeding. What do they do now? I think it's so important to take stock of one's inner dialogue. We can say things to ourselves, hundreds and hundreds and thousands of times over and never stop and reflect that we're saying it to ourselves. So I think thinking about what's going on inside of us and talking to people that are close to us. I mean most people have people that they can talk to more openly than they're talking

to. And that can be complemented with professionals. I mean, I think anyone who has no problems or issues whatsoever should never have psychotherapy, right, which is, you know, my way of trying to be clever and saying every damn human on the planet should have psychotherapy, right? Because it's a way of understanding ourselves better. It's a way of being able to commune with someone without feeling the pressure that we're burdening them, like, you know, personal and professional relationships help us understand each other better.

Go to a 12-step meeting, helps a person understand oneself better even, for no other reason, by the feeling of shared humanity. Some of those things which may sound kind of basic, I think, are just of an ordinate importance. An ordinate importance of, take stock of what's inside of you, connect with people around you. That may sound right, but most of us are not doing it, or not doing nearly enough of it. And in terms of literature or books, I mean, I tend to have very, very few book recommendations. I'll say a couple of the standards that I say when people ask me, I would consider reading

K-Moos the plague. You know, the plague is about a city that is afflicted by the plague, but it is also about the afflictions of all of us that are we all living amidst the plague, and are we all living amidst threat to our life and health and safety? Yes, we are. And I think it is a way of potentially thinking about and framing things inside of us, this feeling often of being beset upon and needing a sense of community and a sense of mutuality that we often don't acknowledge.

And I think for that reason, the book is of tremendous value. Some of the very different recommendation is read some short stories by Catherine Mansfield. I think that, yes, check off for those wonderful, brilliant short story writer, but my favorite in terms of evoking the realness of being human, subtle nuances of human interaction, I think is actually best evoked by Mansfield. And I think if we're searching for a way of identifying with our own humanity, I think

those two authors can help us get there. So it's not the most typical literature to recommend, but I think exploring things that great writers have written that help elucidate our humanity is a good thing if one is trying to gain a greater grasp on what's going on inside of us and what may be really driving us to misery. And I think those things in gender compassion and compassion for self is what can ultimately lead somebody to take that step of getting help. Right?

As we have to feel like, hey, there's something going on inside of me that I've been hiding and that I feel really ashamed of. I don't want to feel ashamed of anymore, I don't want to hide anymore. And in general, people won't take that step unless they've engendered some compassion for themselves. Paul, there are so many other things I want to talk about. I'm looking at my little note pad here where I had just scribbled down other things to talk about that. Amazingly, we literally did not get through half of what I wanted to talk about.

We didn't get into, you know, the real understanding of distressed tolerance, the completely nuanced geeky discussions that we have over dinner about all of the different pharmacokinetics of every class of drug and every neurotransmitter. I think the only real remedy for this is we have to do this again. So I think there needs to be a part two of this discussion where we can get into all of these other things. And perhaps between now and then I could try and become less annoyingly long-winded. No, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no,-winded. No, no, no, no, no, no. We don't have a lot of work on that. We don't have a lot of work on that. We don't have a lot of work on that.

Despite the short tenure of this podcast, I've already been given feedback by a few friends who have said, Peter, we are really loving your podcast, but can you shorten it? I would really like to just have a 30-minute podcast. And I've said, honestly, I appreciate your feedback, but that's not what I'm trying to do here. One is I want these conversations to be the conversations that we have. And what we just discussed tonight, the only thing that separates it from a normal discussion

is we have these microphones in front of us, and we're not eating a meal. Right, I mean, there's very similar to conversation you and I had three weeks ago while we were sitting around the same table eating really good Indian food. Right. Now the fact that I'm in the middle of a one week fast makes that image particularly distressing to me right now.

I don't appreciate that. But I just see part of how I keep myself in business is by causing trauma. Yeah. You just cost a shit ton of trauma in me by reminding me of that incredible lamb vindaloo that I was eating sitting right where you're sitting now. And I'm not going to have any of it tonight because I'm going to live in something. I'm going to.

Well Paul, I can't thank you enough for all of the insights you've brought to all of these topics from depression, suicide, trauma, shame, all of these things that are, I think near and dear to our hearts, but more importantly, kind of near and dear to the hearts of pretty much everyone who's listening. I know I said there's a lot more I'd like to get into. I think we should certainly plan to sit down again and talk more about this stuff. I believe that there's a lot here that people can take with them and hopefully at least take some steps that can improve the

quality of their lives. I've said it before, I will continue to say it. I don't think it makes much sense to fixate on living longer if you can't on some level rectify being happier. And that seems to be, you know, if we talk about diabetes and all these other things being diseases of civilization, there may be no greater disease of civilization than our unhappiness.

Yeah, it's probably a good time for me to say, you know, what I truly believe, which is I'm honored that you have had me on here and I really do mean that. I do think that the things that I have to say from the mental health perspective, not because I'm saying them, but because mental health undergirds, you know, our ability to live good lives are so important.

And I think it's a testament to, you know, your sort of relentless drive to understand things better that make a difference to the lives of the people that you take care of that has you looking at elements of the substructure that people often ignore. So I consider it an honor and a privilege to be on your podcast and to be able to talk about things that I think are really are so important and that are just so often overlooked. So I thank you for the opportunity to get the word out in a way that I hope ultimately helps some people. Thank you. Paul, I have no doubt that it will.

Thank you for your generosity of time and insight. Welcome. You can find all of this information and more at pterotiamd.com forward slash podcast. There you'll find the show notes, readings and links related to this episode. You can also find my blog and the Nerd Safari atari at peteratiamd.com. What's a NerdSafari you ask? Just click on the link at the top of the site to learn more.

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