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

0:00Welcome to Huberman Lab Essentials, where we revisit past episodes for the most potent and actionable, science-based tools for mental health, physical health, and performance. I'm Andrew Huberman, and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. And now for my discussion with Dr. Paul Conte. Paul, thank you so much for being here today. Thank you so much for having me. We could just start off very basic and just get everyone oriented. How should we define trauma? I think we have to look at trauma as not anything negative that happens to us, right? But something that overwhelms our coping skills and then leaves us different as we move forward.

0:41So it changes the way that our brains function, right? And then that change is evident in us as we move forward through life. We can see it in mood, anxiety, behavior, sleep, physical health. So we can identify it and we can also see it in brain changes. If trauma rises to the level of changing the functioning of our brains, then there's almost always a reflex of guilt and shame around the trauma that can lead us and often leads us to bury it, right? To avoid it, which is exactly the opposite of what needs to be done. We need to communicate and put words to what's gone on inside of us. And very often a person knows, but they're not admitting it to themselves because they're afraid of it, right?

1:24They don't know what to do. But if they start talking, then they'll talk about the event or the situation. It could be something acute or it could be something chronic that really has been harmful to them, right? And then they feel different afterwards. But that doesn't always happen. Sometimes it's a process of exploration, you know, through dialogue, right? Whether it's written or whether it's spoken of the person sort of exploring the changes inside of themselves, maybe changes to their self-talk inside, changes to their thoughts about the world and whether they can navigate safely and readily in it.

1:59And it anchors as I talk about this, the example I'll use at times is the example of my own life where when I was much younger in my early 20s, my younger brother took his life by suicide. And the response of guilt and shame and hiding all of it inside of me was, it's just very dramatic, but I wasn't acknowledging it, right? because I didn't know what to do about it. And I felt guilty and I felt responsible and I felt ashamed. So there was an avoidance inside of me. So I didn't see that the change was in me, but I was taking care of myself poorly. Like there was enough going on that was unhealthy that I couldn't avoid the realization that like, hey, I'm different now.

2:47And in these ways that are automatic, my reflex to, can I make my way in the world? Can I have a good life? Can I be happy? My reflexes to that were all different. and they were coming through the lens of heightened anxiety, heightened vigilance, a sense of guilt, a sense of shame, and a sense of non-belonging in the world. And was ultimately good and helpful people around me and my own realization. And hey, things are not going well, right? That led me to then get some help and to be able to talk about it and realize like, oh my gosh, I need to face these things that are going on inside of me.

3:19Why do you think that when we experience trauma, these things that we call guilt and shame surface, those emotions must exist in us for some reason. But in this case, it seems like they don't serve us well. So why is it that we seem to be reflexively wired to feel guilty and feel ashamed when that's the exact opposite of what we need to do in the case of trauma? There's something adaptive that has happened in us through evolution that now becomes maladaptive in the way we live in the modern world, right? So if you think of through most of human development, people weren't living that long, right?

3:58And the idea was to survive and reproduce. So traumatic things that happened to us, it would make sense for them to stay with us, right? So if you ate a new food and got really, really sick, it's like you better remember that, right? If you see someone from the group of people a couple miles away, and one of those people attacks you, it's like you better remember that. So the traumatic things that are sort of emblazoned in our brain are built to last. Things that are positive will generate some emotion inside of us, but things that are profoundly negative are much more likely to stay with us. And I think that that was adaptive when all of that was about survival.

4:40right? And I think the same thing is true with, say, shame. The limbic system, right? The system often is called the emotion system, right? In our brains has actually, of course, varying function, right? And one aspect is affect, right? So affect is aroused in us. It's created in us without our choice, right? So if we're walking down the road and someone jumps in front of us or pushes us, then there's a response of fear, anger, heart starts beating faster, more blood to the muscles. We're getting ready to fight or run. And then we become aware of it. So the aroused affect in us is also about survival and it has a very deep impact upon us.

5:28And shame is an aroused affect. So it can be raised in us without our choice and it's very powerful, which if you think about that is an extremely strong deterrent. Imagine a tribe or a group of people that are sheltered together and someone eats half the food at night or something. And there's a very negative response. And that person feels shame because shame is so powerful to control behavior. So the way that trauma can change our brains and stay with us in a way that says, be more vigilant, look at the world in a different way, act more defensively. and how that links to shame and to guilt.

6:10And then guilt becomes what gets called feeling technically, where we relate the aroused affect to ourselves. So shame, the aroused affect and guilt, the next step when the shame gets related to self are such profound behavioral interventions and deterrence that you can see, I think how evolutionarily kind of all makes sense. If we're fighting for survival, you know, and we're an elder statesman, if we make it to 20, this makes sense, but it doesn't make sense in a world where we live much longer, right? We navigate in all sorts of different ways. And there's so much coming at us that can be traumatizing.

6:51Our brains are built to change from trauma, but not in the way we experience trauma and not in the way that we live life in terms of the nature of living life and the duration of life in the modern world where these traumas that happen to us are often so bad for us because they change how our brain is functioning and then our entire orientation to the world is different. And that could be for, you know, years and years. I'd like to take a quick break and acknowledge one of our sponsors, Function. Last year, I became a Function member after searching for the most comprehensive approach to lab testing.

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8:35As a consequence, I decided to join their scientific advisory board, and I'm thrilled that they're sponsoring the podcast. If you'd like to try Function, you can go to functionhealth.com slash Huberman. Function currently has a wait list of over 250 ,000 people, but they're offering early access to Huberman podcast listeners. Again, that's functionhealth.com slash Huberman to get early access to Function. This idea that I've heard about before, I think it was a Freudian concept of a repetition compulsion. My understanding of this concept of the repetition compulsion is that we all want to solve our traumas and it allows us to put ourselves into micro or again, macro versions of that over and over again.

9:18We get to run the experiment again and again in an attempt to solve it. Why is it that somebody who is in an abusive relationship goes on to have a second and third or fourth verbally or physically abusive relationship. We see that over and over. It's not necessarily in everyone, but boy, it is in a lot of people who have suffered trauma. On the surface of it, it makes no sense. But then if we think, well, how does our brains actually function, right? We're sort of trained, at least in Western society, I think, to think of ourselves as logical creatures, right? That like, oh, we're logical and ultimately everything in us can just boil down to logic.

9:55which is completely not true. The limbic system, right? The emotion system, so to speak, inside of us always trumps logic, right? If you think about, does it ever make sense to run into a burning building? I mean, logic says no, right? But if someone you love is in the burning building, people run right in, right? Because the limbic system says yes. So when logic and emotion come head-to-head, emotion wins all the time. And the limbic system does not care about the clock or the calendar. So how I would relate that to the repetition compulsion is when people are repeating, what they're trying to do is to make things right, right?

10:35With the idea that if we can repeat the situation and make it right, it will fix everything, right? Which makes perfect sense if we think, well, where is that concept coming from, right? It's coming from the emotional part of the brain that wants relief from suffering of the trauma and does not understand the clock or the calendar. So if I can solve something now, I will also solve something in the past, right? Which is why I can't tell you how many times I've sat with someone and said, we're starting to do therapy, right? And a person will say, my last seven relationships have been abusive. And I'll say back something sometimes like, well, look, if you tell me that you've had seven relationships that have been abusive in different ways, I'll agree with you.

11:22Like I only say that because that's never what someone says, right? But I think what you're going to tell me is you've kind of had the same relationship seven times. So the light bulb that goes off, like I have not had seven different abusive relationships. I have had one that I have repeated seven times. and now we start getting to what's really going on and what needs to happen. That person needs to face what happened in that original abusive relationship. And it always comes down to the same sort of concepts of the person feeling terrified while the abuse was going on, feeling guilty, feeling ashamed, feeling like, oh, they brought it on themselves.

11:59They deserve it. They don't deserve anything better, right? Because the brain is trying to make sense of it, right? Or I thought I could make that okay, but I couldn't, right? And then there's more guilt and more shame. And if that's stuck inside of someone, like that's bundled up inside of someone, like a medical abscess inside a person, a walled off infection inside the body, this is the same concept in the brain, then of course the limbic system is gonna wanna fix that. And it fixes it by trying to, let's recreate that situation and make it right this time. I see that play out clinically over and over again.

12:35And why do things get better? because we go to the trauma and we unlock it. It's not hidden inside where it can control things, right? We bring it to the surface and then we can take away its power. The thought about the thing, the event or events, plural, evokes this arousal, this internal state that makes some people feel sleepy and exhausted. Other people feel really anxious. Other people feel angry. I mean, arousal has all these different dimensions, as you know. It's clear we need to confront these things. And so how do we deal with arousal? How does one take what they feel inside about something shameful?

13:12What do you do with it in a moment? And does that have to be done in the presence of a skilled trained therapist? How do we deal with that internal arousal? We so often try and change the trauma of the past in order to control the future. And what that really adds up to is the trauma of the past dominates our present. and then we're not really living in the present, right? As we're trying to control the future, we're not gonna do a great job of controlling our future if we're not really living in the present. And so the way to come at that, again, in the moment, if we're saying, okay, in the moment, if I need to fall asleep, right?

13:52I might say, okay, let me try and put that out of my mind. Let me try and thought redirect. So there's short-term strategies that can let us be functional in the context of these changes. But the answer is to go look directly at that thing. Look at that trauma, explore that trauma. And sure, that can be done with a professional and sometimes that's what makes sense. But not always, right? Sometimes it can be done by talking to another person, writing it down, right? Look at what's going on inside of me that my mind is so stuck to this. Let's explore that. We're so afraid so often of looking at the trauma that has changed us, that we'll look anywhere but at that.

14:35What ends up happening is when the person puts words to it, right? It could be in writing, it could be talking to a trusted other or with a therapist, right? Things start to change. I mean, just the fact that you can talk about it, you can put words to it and other people don't recoil. That example of the person who says, okay, I was abused by a coach when I was a child. And once they start talking about it, then they start talking about how, you know, they were just innocent kids, right? Like they didn't know and like they really wanted to be on the team where this coach was treating them as special.

15:08And now they can look at themselves from the outside, right? They can look at themselves like they would look at someone else. You think it's so easy for us to see what's real and true if it's someone else, right? If you ask someone, what do you think of someone who's 10, 11 years old who's abused and manipulated and abused by an adult. We say, oh my goodness, I feel compassion for that person. But if it's us, then oh no, it's guilt and shame and we have to hide it away. And when the person starts looking at it, they can sort of see it from the outside and it starts to take the energy out of it.

15:42All the guilt and shame inside the person gets juxtaposed to like what really happened there? And then they say, right, I was a terrified child. and understand at all, and they can come to a place of compassion. And now we are working against the guilt and shame. And if the person cries about it, that's great, right? I mean, crying is one of the best coping mechanisms we have. It doesn't hurt us and it lets us grieve things. We can't grieve if there's guilt and shame inside of us. It just blocks grief, right? It has to be a clean slate in a sense in order to feel sadness. And then you see that it shifts from anxiety, anger and frustration, usually directed towards the self, guilt and shame, towards being able to process it and being able to bring to bear some compassion and being able to direct the negative emotions, so to speak, where they're warranted.

16:35And my goodness, the changes. It's remarkable how just getting it out there and having like one hour of talking like that, like what we're talking about now can leave a person feeling immensely better. How do we do that in a way that isn't re-traumatizing ourself in a major way or in a minor way? It starts with real introspection. When things are bouncing around in our minds, often it's very non-productive, right? It's the same thing over and over again. And that's not helpful for us, right? So if we're just thinking about it and we're thinking in the same way, we sort of, in a sense, always think about it, then all we're doing is reinforcing the trauma, right?

17:14But if we can distance enough, then we can think in ways that allow us to have new thoughts, right? That we weren't having. It's not just bouncing around in our minds. And if we speak or write, there are even more mechanisms that come online in our brains, right? That are then sort of monitoring mechanisms. We think in a different way if we're using words, right? And we are better able often to bring in that observing ego, Like what's going on inside of me? So, so it can be very helpful to think it can be helpful to talk to someone, to a trusted other, you know, friend, family, clergy, uh, to write.

17:51I mean, these are things that can be done without expending any resources. And sometimes if the symptoms are significant enough, like we really do need to talk to somebody professional who can, who can help us get to the root of the trauma. I'd like to take a quick break and acknowledge one of our sponsors element element is an electrolyte drink that has everything you need and nothing you don't. That means the electrolytes, sodium, magnesium, and potassium in the correct amounts, but no sugar. Proper hydration is critical for optimal brain and body function. Even a slight degree of dehydration can diminish cognitive and physical performance.

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19:35But what are some of the characteristics that one should look for in looking for a therapist? If you look at what are the top 10 important factors to find in a therapist, just repeat rapport 10 times. It's trust, it's a back and forth. It's like, yeah, even though I'm doing something difficult, I'm doing it with someone who's really helping me, someone who's in it with me, right? Someone who's really paying attention, wants me to be better. That's indispensable. I think that good therapists are not pigeonholed by a certain modality. They may come at the world largely through a psychodynamic or a CBT or a DBT lens.

20:11There's lots of different ways to do therapy. But when you really talk to those people, really good experienced therapists, it's all coming through the vehicle of the rapport, but they're practically shifting to what the person needs. If you have that, you've got a winning combination. So people should perhaps try a few therapists and maybe have a session or two or three to see if the rapport feels like it's taking root. Yeah, and I think that's why word of mouth is important, right? If someone you trust tells you, hey, this is a good person, that says a lot, right? It already makes the pretest probability quite high.

20:44How does one gauge how much therapy they ought to be doing? And should it always be on the therapist to decide that? Yes, I think a lot of times it would be the therapist to say it looks more intensive work or can make a difference. but I think the person also needs to take ownership of their own therapy and say, if I don't feel helped enough, well, I have to think about that, right? And talk to the therapist about that because maybe that therapist isn't a match. People can get into a rhythm of therapy where it's really not helping them, right? But they either feel sort of nihilistic about it, like, oh, I'm no better and I'm going to therapy.

21:21Do we really need to look at ourselves? And this is where the insurance systems often are very difficult because it's hard sometimes for a person to say, oh, I need more therapy because that may not be possible. So there are sort of negative factors in the world around us. But ultimately, I think the answer to the question comes down to observing ourselves and taking ownership of like what's going on in us and how we're feeling. And then feeling that commitment to self or to self-care to say, I need to go change this. Now, I'd like to talk a little bit about chemistry. Yes. Drugs. How do you think about prescription drugs in the context of treating trauma and other conditions.

22:00I think that we tend to over-utilize medicines in this country because we have a healthcare system that often, that's so based on throughput that we want to polish the hood when there's a problem in the engine, right? So we over-utilize medicines often as an endpoint, right? Oh, we're going to make that person's depression better with an antidepressant. Most of the time, for that person's depression to really get better and stay better, they need to unravel what's driving the depression. So the first kind of branch point can be, what is the diagnosis? What is the level of severity? And I think that's very, very important.

22:36And the vast majority of people who are helped by antidepressants, they don't have clinically severe depression. Those medicines create more distress tolerance in us. If you can improve someone's distress tolerance, and you can use medicines that take away what clinically is rumination, Not the standard meaning of that word, but the clinical meaning of it where there are distress centers in our brain that are overactive. And then we get stuck in these maladaptive negative pathways where we think about something over and over and over again with no real chance of solving it because that's not what's going on inside of us.

23:12So medicines can help that, but we have to have some flexibility around their conception. And the modern medical system of the 15-minute visits to a psychiatrist that are weeks apart, I mean, I don't understand how that goes well. We use, I think, approximately five times as much medicine, I think, across the board as, say, the Dutch population. They have a healthcare system and a cultural system that, to the best of my understanding, is more rooted in taking responsibility for oneself. So if a person comes in and cholesterol is high, the first order of business is, hey, you could take better care of yourself, right?

23:48Like this person really needs to lose some weight, exercise more, right? They're not just jumping to like, let me give you a medicine and shift you through the healthcare system and out the other side of the door. So I think medicines get overused in large part for systemic reasons and also for some of these categorization reasons. Oh, that person meets some technical criteria for depression. We got to give them this medicine instead of really thinking, wait, what's going on in this person? And I see this over and over again. And I see someone who's on seven medicines and they're on seven medicines to treat seven different symptoms.

24:20And now they have side effects from all those seven medicines. Maybe two of them are to treat the side effects from the other five, right? And that's bad. I'd love to talk about psychedelics with the preface that we're talking about this in a legal clinical setting. What are your thoughts on these drugs for therapeutic potential, also potential hazards, et cetera? The data coming from the labs and the academic centers is so powerfully positive. These are used in professional hands and with the right kind of guidance are extremely powerful tools, but used in the right way. What happens is we see less communication, less chatter in the outer parts of the brain, right?

25:04In the outer parts of the cortex. That's where language is. That's where vision is. That's where executive function is. so planning and task execution. So, so much of that is about making our way in the world around us. And I think when we take the neurotransmission out of those places, right, and we set it in a part of the brain and say the insular cortex, right, the parts of the brain that are sort of in the middle, right, which I think, I believe is where our humanness really is. So the psychedelics make there be less chatter, communication, these other parts of the brain. And then we become seated in the part of the brain that I believe is most about our experience of true humanness.