Please enjoy this transcript of my interview with Dr. Paul Conti. Dr. Conti is a graduate of Stanford University School of Medicine. He completed his psychiatry training at Stanford and at Harvard, where he was appointed chief resident and then served on the medical faculty before moving to Portland and founding a clinic.
Dr. Conti specializes in complex assessment and problem-solving, as well as both health and performance optimization, serving patients and clients throughout the United States and internationally, including the executive leadership of large corporations. His new book is Trauma, the Invisible Epidemic: How Trauma Works and How We Can Heal From It.
Transcripts may contain a few typos. With many episodes lasting 2+ hours, it can be difficult to catch minor errors. Enjoy!
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Tim Ferriss: Hello, boys and girls, ladies and germs. This is Tim Ferriss, and welcome to another episode of The Tim Ferriss Show. I am thrilled to have my guest with me today, Paul Conti, MD. Paul is a graduate of Stanford University School of Medicine. He completed his psychiatry training at Stanford and at Harvard where he was appointed chief resident and then served on the medical faculty before moving to Portland and founding a clinic. Dr. Conti specializes in complex assessment and problem solving as well as both health and performance optimization, serving patients and clients throughout the United States and internationally, including the executive leadership of large corporations. His new book is Trauma: The Invisible Epidemic, subtitle, How Trauma Works and How We Can Heal From It. You can find him online at drpaulconti.com and also at pacificpremiergroup.com. Paul, so nice to see you, my friend.
Dr. Paul Conti: Thanks so much for having me. It’s great to see you too. I appreciate it.
Tim Ferriss: And I have been looking forward to this conversation in my mind’s eye for some time because we’ve known each other for a while. We met through our mutual friend, Peter Attia, and I saw a very early manuscript of Trauma: The Invisible Epidemic. We were doing the math beforehand, before we pressed record, around two and a half or so years ago. And I was so thrilled that you were putting your experiences and your approaches into book form. The fact of the matter is most of the time when I have every friend, acquaintance, and their cousin and grandma telling me they’re going to write a book or asking if they should write a book, I spend most of my time dissuading people from writing books. A, because I think there’ll be just redundant or not a great value-add. And then on top of that, I really just don’t want to be forced to read them. And my feeling with you is very much the opposite. You are such a deliberate, thoughtful, and skilled practitioner.
And I also of course value you as a friend, but I’ve had a chance — and I’m not going to disclose details necessarily — but I’ve seen you really intervene and quite likely save lives. And I can’t say that for many people. So it’s a real honor to have you on; I’ve been looking forward to doing this for a very long time. I have the highest opinion of you — just to establish that up front. And with all of that, let’s jump in. And I would love to hear also, because my memory needs refreshing, but for people listening, how you ended up in psychiatry?
Dr. Paul Conti: Thank you. And I want to thank you for your support when I was really figuring all this out and deciding, I really want to write a book and it’s such a leap to take that your support and encouragement about how that would be a worthwhile endeavor and could really make a difference was so helpful to me two and a half years ago and before then too. So I’m so appreciative of that. And it’s sort of part of my circuitous route that I had no pre-medical classes in college and I had a business career and at some point in time, I realized that what has unified my interests across time was really about people. So I studied history and political science and art and I was very interested, but ultimately it was really into people. And that’s what was also fueling my interest in business was the people I was engaging with. And what were they like and how do they have these thoughts that got them to where they’re at?
And it was that sort of unifying element that led me to go back to medical school and say, “Okay, I’m going to learn about human biology and just learn something about human beings.” And it was there that I realized like, oh, you can take this medical knowledge and you can take the sort of life knowledge of whether it’s history or politics or sociology, just knowledge about human beings. And you can put that together with an individual person who’s sitting in front of you and talking about them like the specifics of their life and their experience. And you can put all that together and really be helpful to people, like really make a concrete difference that you can see that there’s a change. And that was ultimately so appealing to me and I felt like I could get that through psychiatry. And I think I found that to be the case. I’m so grateful for the vagaries and the idiosyncrasies that ultimately led me to be able to see all of this and choose it as a career.
Tim Ferriss: Many follow-up questions, but we’re going to kind of flash-forward to current day, and then we’re going to flash backwards. So I want to read a little snippet from the foreword in your book. And I think you’ll recognize this. Then I’m going to ask you to add context.
Dr. Paul Conti: Okay.
Tim Ferriss: “‘Why didn’t you bring a real doctor?’ I asked the nurse. Paul replied by saying, ‘I’m an Italian from New Jersey.’ And that’s when I decided I was willing to talk to him. My dad is an Italian from New Jersey, so I figured I at least knew what I was dealing with.” Whose words are these?
Dr. Paul Conti: Those were the words of Stefani Germanotta, who’s also Lady Gaga, on our first meeting. I think what I would describe as, I think, our auspicious first meeting.
Tim Ferriss: So she wrote the foreword to Trauma: The Invisible Epidemic. Of course, you didn’t start off with clientele or clients, patients like her. Could you tell us a bit about, since we’ve mentioned the title a number of times, your own personal history with trauma, if you’d be open to sharing?
Dr. Paul Conti: In the first part of my life, say, up until around early twenties, I didn’t have major trauma in my life. And in some ways I was fortunate to get through the big developmental milestones without major trauma. And it gave me a sort of view of life that was then deeply challenged by a sequence of traumas that sort of came in the second part of my life and seeing how they made me feel differently about things because I had the sort of foundation of confidence in myself and also in the predictability of the world that if I’m engaging and doing the right things, the good things are going to come back to me, and how differently I felt. One after my brother’s suicide, which was the first of a series of quite traumatic things that unfolded over a number of years, the challenge of that, of realizing that while I’m trying to figure out my way through this and like how to go on with life and how to support my parents and the people around me, while I have an awareness that like, “I am different.”
Now, I’m seeing the world differently. And all of a sudden, I remember I feel a little bit like, “Am I cursed? Is my family cursed? Is anything going to be okay? Maybe bad things always happen.” I was so off balance and in way, kind of impacted, impaired, even, by all of this and realizing that, “Well, can I even trust how I’m thinking?” Because I’m thinking differently, then I’m trying to use the brain that’s thinking differently to figure out what’s different. And there was something quite scary about that, that I could also, then I could see, when I became a psychiatrist, play out in the people I was trying to guide or advise or take care of, that they also often had thought differently about themselves. They stopped seeing that they could make their way in the world, that they had good things to offer, or that they could even stay safe. And that, for me, like really caught my attention that, “Hey, there’s something going on here that’s very deep and also very insidious.”
Tim Ferriss: Thank you for sharing. And I just want to echo some of what you’re saying in my own personal experience with depressive episodes, which I’ve had as a mainstay of sorts for most of my life. And it can be very terrifying and certainly disorienting, say, in the middle of a depressive episode, to be aware that you are looking at the world through a distorted lens, but to have no confidence that you can correct that lens. It can be very terrifying because you feel like the prism through which you are looking at reality is broken and you’re aware there’s a problem, but you can’t look through that broken prism to fix the broken prism or so you might believe, and it can be extremely disorienting and sometimes destabilizing for sure.
And I wanted to ask if you might be willing to speak to some of the other traumatic events and to place us in time, starting with perhaps your brother. How old were you when your brother committed suicide?
Dr. Paul Conti: I was 25 at the time, 25 years old.
Tim Ferriss: And are you willing, if you are willing to share, would you be open to mentioning some of the other things that happened to you? And the reason I’m asking about this is not to inflict pain in revisiting these things, but rather to share your personal experiences because there are very likely going to be people listening who will identify with different parts of your story.
Dr. Paul Conti: I understand, and I think it is helpful. The context is helpful. And I think it speaks to the impact of repeated traumas. That not long after my brother’s death, one of my best friends, a person I grew up with, died, died very unexpectedly. We were in our mid-twenties. Several years down the road, my wife was injured and injured quite seriously. I lost another very close friend under very tragic circumstances a couple of years after that. There were other traumas that were interspersed that weren’t at that level. So there’s a sense of continued negative things happening.
My mother became ill with pancreatic cancer and died not that long after her diagnosis. And that was very painful for very many reasons, including the feeling that my brother’s suicide and the impact upon the family had maybe predisposed her to getting sick, which there may be some truth to that, there may not. We can’t know the answer, but that oppressive feeling of like, there’s one bad thing after another, and I can’t control any of it and amidst it if I’m not really grasping to get to keeping a hold on my sense of self that I could potentially lose that too, or a sense of my place in the world. The idea you described of, say, what amounts to learned helplessness. That says, “I see these bad things. I see what they’re doing to me, but I don’t think I can change any of it,” that there was a real danger of that throughout that whole period of time.
Tim Ferriss: And if we focus on this term we’ve used now a number of times, trauma, how do you suggest people think about or define this term? And I’ll probably do this quite a bit in our conversation just to ensure that everyone understands the way in which we’re using certain terms, but how would you suggest people think about trauma and if there are subsets or different types of trauma, perhaps what those are?
Dr. Paul Conti: I would describe trauma as anything that causes us emotional or physical pain. That surpasses our coping mechanisms, that makes us feel then overwhelmed, often overwhelms our nervous system, both body and mind, and then really leaves a mark on us as we move forward. And trauma can be acute. A single traumatic event, an assault, a car accident, an injury in combat. Trauma can be acute. It can also be chronic. So the chronic impact of, say, ongoing abuse or ongoing neglect, or even ongoing marginalization. And we see so much of this has come to the forefront, whether that’s gender identity or it’s racial. How many people are trying to exist and doing their best to not just to thrive, but doing their best to survive amid circumstances that are constantly telling them that they’re less than, or that they’re at special risk? That’s chronic trauma.
And vicarious trauma comes from really this wonderful fact that we can be empathic and empathically attuned to other people and we can feel what they’re feeling. That’s a wonderful thing that we can do that for one another, but it also makes us so susceptible to other people’s suffering and pain, and we can lose the boundaries of what is us and what is them? I’m not the only physician to say that at times, especially in the intensity of the training period, would have to really stop and say, “Okay, wait a second. What is happening now is happening to someone else, not to me.” Because if I don’t maintain that boundary, I’m too overwhelmed to help them, but if one is empathically attuned, which many, many people are, then we don’t bound ourselves from other people’s suffering. So there’s acute trauma, chronic trauma and vicarious trauma. And of course, an overlap, there can be an overlap between them too.
Tim Ferriss: I’d like to — since we’re also, you and I, catching up, ourselves as friends, not just doing an interview.
Dr. Paul Conti: That’s great.
Tim Ferriss: I’d love to share. It’s really, really great to see you. And I’d like to share an experience, maybe in the last category.
I don’t want to give it a capital T, but I’ve had a new experience and I’ve never passed through this type of shift in myself, I don’t think. An acquaintance, I don’t want to say friend, but someone I know had a horrible family tragedy not long ago. His teenage daughter was killed in a head-on collision with a large truck, like a Mack Truck. And for reasons that I don’t think were necessarily determined, her car just swerved ever so slightly into the incoming lane and dead on impact. And since that news, I get exposed to tragedies every day. I mean, if you look at the news, you buy the newspaper, there are tragedies everywhere. So I don’t know why this had such a disproportionate, I don’t want to say disproportionate, but such a large impact when I’m exposed to tragedy of other types all day long. But I have had extreme anxiety while driving almost every day since that happened.
Dr. Paul Conti: Right. I can understand that.
Tim Ferriss: And I don’t want to take, necessarily, an anxiolytic just to mute the anxiety or to suppress the symptom, but in a case like this, just because perhaps it’s maybe easier to tackle than something like the childhood abuse that I experienced when I was really young, how might someone approach this with or without professional help? And maybe this isn’t the forum in which to discuss it, but I’d love to hear any thoughts you might have, because I’ve never experienced anything like this before.
Dr. Paul Conti: Tim, I think it’s a great forum for it because it speaks to a common problem and a general principle in approaching the problem. We have to divert our attention from our instability and the unpredictability of the world around us. Like on some level, we know that anything could happen and we’re not safe from moment to moment from tragedy. But we have to sort of set that aside, where it’s kind of in the periphery of our mind and that’s what lets us be able to go on and live our lives.
Tim Ferriss: Right.
Dr. Paul Conti: And things will happen sometimes that really resonate with the person. Now here, it may be that something makes you really identify with this person even though they’re an acquaintance and say, not one of your closest friends. Or it just may be that something about the story or even something about your own condition, the fertile ground inside your mind when you hear the story. That makes it resonate with you. And then in this, that’s a very classic aspect of vicarious trauma. Then it resonates and you feel as if like that’s happened, you get some shadowing of what that must feel like for that person. And then it shakes your sense of stability and predictability and this ability to control the world around you and be safe.
And that starts making you feel insecure, vulnerable. It’s a natural response and the thing to do about it is to validate it. That’s really the primary point, I would say in response, is to validate it because what people most often do is the opposite. It’s unpleasant. It feels so bad that the person wants to say, “So there’s something wrong with me. Why am I feeling this way about this? It didn’t happen to me. This isn’t someone in my close family.” And we try to somehow invalidate what you’re experiencing, instead of saying, “No, it’s understandable.” This is reminding you of something that you do actually know is true, but it’s bringing you to the forefront of your consciousness, the vulnerability, the unpredictability, difficulty controlling the world.
And if we validate that and realize, “Okay, I’m not learning anything new from this, but I’m feeling something very strong and I want to honor that I’m feeling that.” And then to be able to put words to it with someone that you know and trust and to be able to say that helps to pay down some of the anxiety and distress that often gets worse if the person is trying to shove it down and invalidate it. “What’s wrong with me that I’m feeling this way?” It just grows that tension inside.
Tim Ferriss: Yeah. Right. That makes perfect sense to me. You have sort of a catalyzing event and then you have — so let’s just call that one — I hesitate to use this term, like one problem. And then if you have a very self, not defeating, but self-critical, judgemental response to it, now you have quite another problem. And as I’m thinking about this, I haven’t really spoken to anyone about this, but I recall at the time, you have me wondering like, “Why did I respond to this in this way?” And I think that the circumstances temporarily — the circumstances at the time had a lot to do with it. I think a number of very difficult, unexpected things that happened in my life, I then also got the news in a somewhat, I don’t want to say frantic, but very urgent text from a mutual friend of this acquaintance and when I called, there was some type of help that I was potentially being asked to provide and I couldn’t provide it. And so —
Dr. Paul Conti: I see.
Tim Ferriss: — I found it very jarring in that respect. So I wanted to share that as an opportunity for discussion.
Dr. Paul Conti: If I could say back, Tim, that makes me think about the sense of vulnerability and in the sense of, “I can’t even do anything to help.” There’s such a sense of vulnerability that then gets reinforced by that.
And often people do want to help, even when there is nothing someone can do to help, and then the person feels bad. They can’t make anything better, make the person feel better. And that adds to that sense of terror, really. If we sort of validate within ourselves, “I’m doing what I can do. I can be here for this person. I can listen. I can let them cry or be upset around me.” That is what there is to do, then that can take away from the sense of desperation and vulnerability and I want to help, but I can’t because that critical voice that you referenced is very, very common in people who are conscientious, which is most people are conscientious people, capable of feeling someone else’s pain. So that critical voice comes to the force so readily, it’s reflexive, which is where the shame comes from. And there’s a whole cascade of, as you said, secondary problems to the initial negative thing or the initial problem.
Tim Ferriss: Thank you for listening and for talking through it. How would you describe the current state of treating — successfully or unsuccessfully or anywhere in-between — trauma? What is the sort of current standard of care and what do you make of some of the tools in the tool kit?
Dr. Paul Conti: The short answer to the question is: by and large, abysmal.
And I think that’s not because the people in the helping roles don’t want to do their jobs or aren’t capable of doing their jobs, but we’ve evolved a system that purveys mental healthcare largely without attention to the actual human being. And this is a huge problem. If you think about the shortening of visits. How much can you really talk about who you are or what’s going on in you in the kind of brief, often rushed and infrequent appointments that we have in our health system? And an over-reliance on medicines, which leads to a paradigm that just wants to basically take a symptom inventory.
Tim Ferriss: Right.
Dr. Paul Conti: So well, tell me an inventory of your symptoms. And I used to say this sometimes when I was teaching, where I would give an inventory of symptoms of a person who had a rock in their shoe. And then often at the other end of that would be like, “Well, what do you think is going on?” And people would often say, “Attention deficit disorder.” Because the person’s not paying attention to things or distractible. But if we just take symptoms, we will get it wrong.
Tim Ferriss: Absolutely.
Dr. Paul Conti: And we will get it wrong a lot and getting it wrong, is it benign? It’s not that, “Oh, no help is given.” Because we got it wrong. Now, it’s actually that harm is done. And the symptom inventory, make a diagnosis or several diagnoses, and then throw, by and large, medicines at the diagnosis, just doesn’t work. And what we end up doing is like so much in the American healthcare system, we spend so much, but we are at the bottom in terms of industrialized countries of outcomes and that’s because we waste so many resources by not looking in-depth at the actual problems. And I think we do a very poor job at identifying and processing trauma for all of those reasons.
Tim Ferriss: Are there any places this could be a country, a city, it could be specific clinics that stand out to you as being on the opposite end of the spectrum — either highly effective or, at the very least, more effective with addressing trauma?
Dr. Paul Conti: I have some information and data about what’s going on in some of the European countries, but not enough to comment really with any authority. I think that most of what goes on in America ends up being a very low bar in a very formulaic purveyance of care. There are exceptions. So, for example, The Bridge to Recovery, which is a place that Peter has talked about, and I think is a place that really sets an example of how to be different, and of course it’s a residential facility and not everyone needs to or can go to a residential facility, but that route of approach of really understanding the people and understanding developmental trauma, even if the reason the person is coming to care isn’t specifically the developmental trauma, but realizing that people, we’re all a whole. We’re a whole person with our feelings, memories, that evolve in us over time.
And so they do a wonderful job of looking at the whole person. They’re certainly not the only entity that does that, including individual practitioners. But by and large, it’s hard to find systems that will treat trauma from a holistic perspective.
Tim Ferriss: How do you find the proverbial or metaphorical rock in the shoe? And by that, I know you were giving sort of an illustration of an exercise when teaching, but beyond symptom inventory, how do you begin to unearth the causes at play with someone?
Dr. Paul Conti: What I find so interesting about this is it’s actually not that hard if you can build a rapport with someone where they feel like, “Okay, you’re not looking to fault me, and you’re not looking to stigmatize me, and you’re actually interested in me, interested in what’s going on in me.” So I wouldn’t say to everyone, “I’m an Italian from New Jersey,” but the thought of, “Hey, this is —
Tim Ferriss: That’s not your opening salvo?
Dr. Paul Conti: It’s not my consistent opening salvo. But when someone you could tell is in pain and you’re thinking, “Look, is there a route in which we can connect?” And Stephanie is an Italian from New York, there’s a similarity that can then establish a rapport, that can lead the person with whom I’m trying to establish the rapport to really feel like, “I can talk to you. I can talk, period. I can talk openly.” And it often leads to right where we need to go. Because people often are aware of what’s going on inside of them, what triggers them, what’s going on in the tape that’s playing in their head all the time. How do they feel badly about themselves, what’s their internal dialogue about themselves? And when you let people start talking, very often, they’ll talk about it even if they never have before. They might have had treatment for depression in 15 different settings, never talked about trauma.
I mean, by the way, I see this a lot, that’s not just a theoretical example, because no one’s asked about it and been open to it, and that reinforces the idea of shame and stigma. No one’s asking about this, even though we’re ostensibly here to talk about my mental health. That reinforces the messaging of stigma and shame. But if you give people an open venue to talk, it’s remarkable how it can come to the fore, be processed or validated or challenged, however it may be. It’s just an openness to it which involves a milieu that allows for that to happen, which is something other than very, very rushed like, “Okay, we have 15 minutes, let me hear your symptom inventory so I can write a prescription, and then the next person can come in.”
That’s never conducive to openness and sharing. But if we make environments that are open to that, really good things happen.
Tim Ferriss: I would love to ask a question that might pop to mind for listeners as well. And as just a backdrop, I’ve thought a lot about trauma. I wouldn’t consider myself a domain expert, but I had experiences of sexual abuse when I was very small and consistent regular abuse for several years, from two to four, at a babysitter’s house. And so I thought and read quite a bit related to trauma, but I think it’s important to note, and please correct me if I’m not getting this right, but that you are not a hammer looking for nails with trauma in the sense that you cover a very broad spectrum of different conditions, issues, wants, questions with patients. And it seems to me that there’s probably a potentially damaging, just like the symptom inventory is not neutral necessarily, it can result in very bad outcomes. I’ve done some reading on controversy related to, say, suppressed memories.
Dr. Paul Conti: Right.
Tim Ferriss: So I’m sure there are therapists who actually do a lot of damage by trying to fit a narrative of trauma to every patient that they have in some way.
Dr. Paul Conti: Absolutely.
Tim Ferriss: And so I’d love to just hear you comment on the good, the bad, and the ugly within the discipline, let’s just say, or skillset of treating trauma.
Dr. Paul Conti: The first thing I would say is I never made a conscious decision to say, “Hey, I’m going to be a trauma person.” I mean, what I saw was, “Oh, this is running through everything that I’m doing.” And at the time I really first started seeing it, I had an open general practice, and I was seeing — what are the commonalities across people that I’m seeing? Socioeconomic, demographic background, diagnosis, what are the commonalities? And of course, I saw how often substances were playing into what was going on. And I saw, even more strongly than that, how often trauma was playing into what was going on, whether that was depression or anxiety or insomnia or even the evolution of psychosis or the triggering of bipolar episodes. I mean, there was just so much that was keyed to trauma, and that’s what really captivated my attention and then grew my interest in my research and clinical approaches to it.
I think it’s there, and it’s quite pervasive, but it, of course, isn’t the answer to everything. And yes, if you have the hammer and you want to see all nails, then that’s what we see. And I think we have to be very, very careful because we often, as human beings, we develop allegorical ways of understanding things, and we can do that consciously and also unconsciously. So the idea of recovered memories from the perspective of, “Oh, that person had no idea that that thing had happened, and now they know that it has happened,” is something we just must be skeptical about in a way that’s careful. I don’t mean skeptical in a way of trying to invalidate a person, but being careful because if a story that’s not actually true becomes that person’s touchstone for truth, that is not good for that person. And it can be very damaging for others who then may be falsely accused of something, for example.
Most of the time, and I’ve been doing this for 20 years, and I would say the vast majority of times when someone is now talking about a memory that they haven’t talked about before, it is not because they did not have that memory before, it’s because it was riding in the boundary being above and below consciousness. And they know that that’s there, but they don’t let it into consciousness or, let alone, put words to it. And then there’s a way in which the memory or the experience the person has talked about fits with their internal world before it came to the fore. As opposed to, in a sense, coming out of the blue, which we just need to be more careful about for the sake of that person who may have had that come out of the blue because maybe that’s true, but maybe that’s not. And if it’s not, it’s not helpful to them. And it’s potentially risky to others, if that makes sense.
And the more that we work against stigma — again, I’m saying this because I believe with all my heart that it’s true, that your willingness to talk about your own trauma is so powerful. It’s so powerfully helpful because you’re pushing against reflexive stigma, because trauma makes reflexive shame and reflexive stigma, and that’s what makes people go underground, so to speak, with their trauma. And that’s where confusion comes in. The misery gets compounded, confusion comes in because people are alone with something that’s terrifying them. And they’re alone over time, and their own brains can evolve in ways that, maybe, sometimes are helpful but, maybe, sometimes are not helpful.
So the more that we work against stigma and shame and say, “Look, what is there that’s happened to a person that that person should not be able to talk about with trusted others?” Whether that’s trusted friends and family or clergy or people in helping fields, a person should be able to talk about what’s going on inside of them because it’s burying those unhealthy seeds, so to speak, that then compounds original trauma into something that can end up being far, far worse with a whole cascade of problems. Could be depression, could be substances, could be self harm, could be an eating disorder. There’s so much that gets compounded when the original trauma gets pushed outside of consciousness and outside of communication.
Tim Ferriss: It brings to mind for me something, and I’m paraphrasing here, that someone named Gabor Maté shared on the podcast quite a few years ago. And again, I’m not getting this word for word, but he spent a lot of time working with opiate addicts in British Columbia and elsewhere, and he is fond of saying, “We shouldn’t ask why the addiction, we should ask why the pain.” And certainly, in my exposure to addiction, my best friend from childhood died of a fentanyl overdose. And my brother’s best friend from childhood died in a drunk driving accident, lot of substance abuse where I grew up on Eastern Long Island. And my uncle actually recently died of — I’m not laughing because it’s funny, but alcohol-induced cardiomyopathy. His wife, my aunt, died of Percocet plus alcohol, so I’ve seen a lot of addiction, and what Gabor says really resonates with me.
I would love to, if you’re open to exploring some of the tools in the toolkit, and I’m not implying that you utilize all of these modalities in your practice, but for those people out there who are wondering — and we’re going to talk about the framework of the book and how you put it together and what people who don’t have access to Paul Conti might expect to learn and be able to apply from the book, but before we get there — in the last handful of years, as you know, I’ve been hoovering up a lot as an enthusiastic amateur and have found certain things personally very helpful like IFS, Internal Family Systems, that I found very helpful. I’ve helped fund some studies with different formats of therapy like CBT or — DBT, dialectical behavioral therapy?
Dr. Paul Conti: Yes.
Tim Ferriss: And then I’m hoping, I think I’ve already funded, or my foundation has funded a study involving, these acronyms get really tricky after a while, co-joint or conjoint, something that is conjoint and similar to CBT, but the idea being that you are using, in this case, MDMA-assisted therapy for not just the individual who experienced trauma, and I think in this case, it’s veterans, but also the spouses.
So there are all these different approaches. People may have heard of EMDR, which I don’t have much experience with, but all of these various tools in the toolkit. Are there particular — and this may not be a good question, but I’m curious so I’ll ask. Are there particular modalities, frameworks, tools that you have found to be particularly helpful in working with individuals who have trauma in their background?
Dr. Paul Conti: There are many arrows in the quiver, and CBT is an arrow in the quiver, DBT is an arrow in the quiver, medicines can be an arrow in the quiver. But where it all has to start is a search for truth because trauma changes our emotions about things, our feelings and emotions about things. It then changes how we think and what our memories mean, so we need to look at, “What is the person’s narrative about trauma,” if they’re identifying that there’s trauma, and if not, “What is the narrative about self?” Because unless we understand that, then it’s like you’re trying to solve a math problem, but you don’t know what the equation is.
Tim Ferriss: Right.
Dr. Paul Conti: We’re not going to pick the right tool, we’re not going to get to the right place. So because there’s so much reflexive shame and then a cascade that comes after that, and a lot of times, that involves a decrease in role performance where now, the person doesn’t — they’re not performing their role, say, as a parent or as an employee or as a friend as well, then the person begins to think of themselves in a different way. And the first thing to get at is, “What is the person’s narrative?” So someone who may present and say, “Oh, I’ve really got physically hurt in my last relationship, but I mean, this is always what happens, so it never goes any differently.” I mean, instead of looking, “Okay, let’s look at the trauma from this thing that happened to you in your last relationship,” you have to look at, “Why is the person approaching the whole question of relationships from a place that says things won’t be okay for me?”
What are the lessons that that person has learned that are not actually true? And you have to go back to when did the person start thinking of that. I mean, if people don’t — I mean, I’m saying it for effect, but people don’t pop out of the womb thinking, “No one’s going to treat me well, I don’t deserve to be treated well. I always get hurt in relationships.” Where along did that conception come into play, and how much does that person also, maybe, feel they don’t deserve anything better? Where did that come from? And if we go back and we look at the formation of a narrative that then furthers and perpetuates trauma, then we can get at changing it. But then you have to get at what are the pain that the person felt, the emotions involved. You have to go to a place that’s emotional.
But if you go to that place where the actual events, the emotions, the change in conception of self or conception of the world, then you can come through and say, “Okay, what tools does it make sense for us to apply?” because there are the arrows in the quiver that you noted and a lot more. But the question is knowing, “Hey, when does one make sense versus another?” And I try and write a lot about strategies, antidotes in the book. And I think, in a sense, they’re good ideas, but — I think they’re good ideas, but they’re good ideas only if they’re applied in the right situation, to the right person. So it goes back, again, to understanding the person, what happened to them and what is their narrative of themselves and what the world can or can’t be for them.
Tim Ferriss: Well, let’s get personal, and I’ll be the one to get personal, just as a way of exploring this, if you’re open to it.
Dr. Paul Conti: Sure.
Tim Ferriss: It’s hard, maybe it’s impossible, to say, “I feel X because of Y.” I mean, if it were a scientific study, it’d be very hard to get to conclusive results. Nonetheless, there are certain events in my life and abuse experiences and so on that, I think, have formed my worldview or informed my world view. I don’t want to put it all on that, there’s probably — there must be more to the story, but I’d love to talk about hypervigilance for a second.
Dr. Paul Conti: Sure.
Tim Ferriss: This is from your book. “When people suffer from trauma, however, their threat sensor becomes hyperactive and hypervigilant, convincing them that things are dangerous and wrong right now, constantly. It’s like a threat sensor recognizes that it was unable to prevent the initial trauma, and now it’s trying to make up for it by being active and loud all the time.” This is how I feel a lot of the time, and I’ve approached it from different angles. I’ve used heart rate variability training to start from bottom up, in other words, not starting with the language and the concepts and the stories, but starting with the physiology.
I’ve found that quite helpful with Dr. Leah Lagos, and I feel like I’ve made progress here. But nonetheless, I do feel like my threat sensors are turned to high volume most of the time. And so I have these fundamental stories. And since, I suppose, our stories become filtering mechanisms for what we notice and remember, I can point to long laundry lists of evidence that support what I’m about to say. I’m not saying they’re true across the board by any stretch, but the world is fundamentally unsafe, it’s unpredictable, people should earn trust, but start at a baseline of being distrusted or viewed with some suspicion.
And these positions that I’ve established for myself, I recognize, cause a lot of anxiety, anger, stress that is unhelpful in my life. I recognize — I’m fully aware of this, and I beat myself up with respect to my apparent inability to reformat my hard drive.
Dr. Paul Conti: Uh-huh (affirmative).
Tim Ferriss: Do you have any antidotes for hypervigilance? Do you have a way of thinking about it or approaching it that we could discuss?
Dr. Paul Conti: I come back to the first step being to assess and validate. Think about the things that you said. There’s fundamental truth to some degree.
Tim Ferriss: Yeah.
Dr. Paul Conti: I mean, the world is not an entirely safe place. We can’t control everything, so it’s like too much of a good thing. And that’s what hypervigilance is. Because we’re not saying we should have no vigilance, I mean, there’re threat sensors in all of us that are supposed to be firing in the background. You hear a loud noise, you pay attention. It’s supposed to be in the background. But recognizing that probably, what has pushed, say, that vigilant sensor in you up to a much higher place on the scale is the impact of trauma, which takes reasonable concepts and then builds a whole story around the extrapolation of the concept to some end that is unhealthy and maladaptive.
So take your driving example. So you’re prompted, I think, from — you’re predisposed, say, from prior trauma, to have something that hits home really increase the level of tension and vulnerability inside. So one way of looking at that is to validate and say, “Look, I do actually know that it’s not completely safe to drive,” so I try and I say, “Have a safe car and drive carefully.” I know all of that. But because I hear an example of something really tragic that occurred while driving, then that vigilant sensor wants to build the whole story around that and wants to say, “That’s going to happen to you. The chances of that happening are so high.” And now it starts capturing your attention, and it starts reinforcing itself. And then if you’re thinking, on top of that, “God, what’s wrong with me that I keep thinking that?” that calls attention to it, too, and further reinforces it. But by validating that, “Hey, I’m an empathic person that heard about a terrible tragedy, and the circumstances of that tragedy are going to resonate within me and make the hypervigilance in me attach to that. I know this, I understand this, I can step back to, say, reality testing, of saying, ‘I do actually know that there’s some danger to driving, I do actually take precautions. Me learning about this tragedy isn’t actually making me less safe.'”
And maybe it has me reflect, “Is my car as safe as I want it to be? Is there actually something I can take away from it?” And if I can’t, let me feel a sense of grief for this person’s loss and feel a sense of sadness, but make a conscious boundary that that is actually not about me or my risk in the world. I didn’t learn anything new, and I certainly don’t want to then be beating up on myself because I’m, what, hypervigilant from prior trauma and empathically attuned?
And that’s a place where another example could do, where medicines could be helpful. And again, I’m not saying this because I don’t know enough of the specifics, but sometimes, a little bit of medicine for a short period of time can help push back the extra attention and the extra vigilance to the point where things can then go back towards normal. So there’s so many psychotherapy and medication tactics that can be used, but it starts with, what is the truth of this, what is it actually telling a person, what does it mean to them, what’s the narrative about it, and how do we ground ourselves to the truth of it, as opposed to shame and self-recrimination, even feeling bad that you feel bad?
Tim Ferriss: Just for clarity, the medicines in this case, say prescription medications, could be used to reintroduce my psychology and physiology to a state of non-hypervigilance, so I can recalibrate and recognize it as a possible state. And that is done without the intention of chronic administration or never-ending administration. It is given for a short period of time.
Maybe it’s short, I don’t know. I guess that’s relative, but —
Dr. Paul Conti: Right. That often is effective, and you can go, so to say, top down from brain to body, but you can also go — as you were saying a couple of minutes ago, you can go bottom up from body to brain because tension in the brain makes all sorts of problems in the body. And one very strong example of that is the impact of muscle tension. So there might be muscle tension, for example, between the ribs, and now the person feels a little bit short of breath. Well, there’s muscle tension in the GI system, and now the person is having IBS symptoms, or muscle tension in the legs and now there’s restless legs symptoms, and if we’re — we can go the other way of looking at the body and ways of trying to relax the body and decrease attention to the body because that decreases the signaling that goes back to the brain.
What we don’t want is a cycle where brain is tense, sends those signals to body, body gets more tense, sends those signals to brain that gets more tense. And you can see we can be in a vicious cycle there. So we have a mind-body connection. Whether we choose to pay attention to it or not, it’s still there. And often, if we’re not paying attention to it, it’s not that that’s neutral either, but that can be quite negative. So looking at the whole person, where do you hold your attention, how do you experience your tension, how much in the way of words do you need to put to this, how much in the way to physical interventions should you be doing, should there be any medicines? But again, we’re looking at the person, that becomes very specific to you as it should be.
Tim Ferriss: I would love to ask a question that is specific to you. And this might be a bit of a left turn, but I think it would be — I’m personally very curious. If we could go back to your brother’s suicide, and I know it’s probably not the easiest thing to talk about, but that is a — I mean, it sounds like — it’s hard for me to conceive of a larger event, at least in the vicarious trauma category. What are the things that helped the most in terms of coming to terms with that or healing from that to the extent that you have?
Dr. Paul Conti: I’ll start by saying I had no mental health education or experience at the time, so my initial response was like, “We’re very healthy.” I mean, I felt like it was my fault, I should’ve known, I should have been a better brother. I was probably fairly depressed myself and drinking too much and all sorts of other things, that I was still going along with life but feeling very oppressed, and feeling oppressed, not just externally, but inside. So this idea that trauma changes how we think about ourselves, and then we’re trying to recognize that is like looking at the mirror and saying, “Is that me?” But you don’t really remember what you looked like yesterday.
Tim Ferriss: Right. Yeah.
Dr. Paul Conti: So that was very scary, and a lot of the ways in which I handled it were not helpful or healthy. So ultimately, when I think, “How did I get through that?” it was — Interconnections with other people were absolutely indispensable, that there were people around me who cared about me, who were then reflecting back to me like, “No, you’re a good person, and a terrible tragedy has happened to you,” which is very helpful because they could see me, because they knew me, and they knew me before the tragedy. It was me who couldn’t see me. And they were basically communicating that “Something awful has happened, but you’re the same person you were before, and that’s a capable person and a caring person.” And that was immensely helpful to me. And some of that was through friends and family. And also, I went and got some psychotherapy, which people weren’t really doing. Where I grew up, people didn’t go to therapy.
Tim Ferriss: Where did you grow up?
Dr. Paul Conti: Outside of Trenton, New Jersey.
Tim Ferriss: Mm-hmm (affirmative).
Dr. Paul Conti: And it just wasn’t in the culture, so for me, going and getting therapy even was like something — do I feel embarrassed about that? Do healthy people ever do that? Is that just for crazy people? That was how it was thought of, so I had to do something that, I think, did have some bravery to it, of saying, “Hey, I’ve got to be honest with myself. I’m not doing okay, and I’m getting help from people, and there are people who care about me, but there’s professional help too. And I just found a therapist and she was very, very helpful to me in that basic grounding way. So the impact of others was so helpful because otherwise, I think I probably, there’s a good chance I would’ve never seen myself the same way again, in a way that could have just been worse, and worse, and worse. And that’s ultimately what led me to is this kind of come to a full stop and look at how I was handling my life. And there’s silver linings. I do believe if we work hard enough towards them, there can be silver linings to anything, no matter how bad it is.
And the silver lining was, I looked at myself and I wanted to go to medical school, but thought I’m too old. Why? Because I was 25. Like that’s not too old, but I thought it was, or I couldn’t leave my job, because I was making a good income. And if I went to medical school, I’m going to pay. And all these things were in my head and people were saying to me, “You’re too old. You can’t walk away from your job. And it’s going to cost.” There were so many things that I realized don’t matter. I have my life. And I’m healthy enough that I can go do what I want to do. Now, go do those things. And it was actually quite helpful to me and I decided, “I am going to leave my job. And even though I haven’t taken a single pre-med course, I’m going to go apply.”
And it led me to feel emboldened, but I had to get to a place where I could see myself as a worthwhile and capable person. That’s how I saw myself before his suicide. But there was a whole period of time when I didn’t see myself that way. And it was really other people, both personally and professionally, that were sort of, for me, a bridge to a place I was not going to be able to get on my own. And I think that’s the case for many of us. And when people don’t have access to people who care about them, people who can help them, unfortunately, there’s a lot of secondary tragedies that come of that because we’re interconnected as human beings and we are not kind enough and helpful enough.
I write about compassion, community, and humanity and these basic principles that I think we should be following, because I don’t think they’re rocket science, I think they’re simple, yet we don’t follow them, and then we’re not there for each other in ways that I think we want to think that we are, but we often, we’re not living that in the world around us.
Tim Ferriss: Thank you for sharing. And —
Dr. Paul Conti: You’re welcome.
Tim Ferriss: — you’ve turned into one hell of a bridge yourself.
Dr. Paul Conti: Thank you, that means a lot to me to hear. Thank you so much.
Tim Ferriss: Yeah. It’s true. I would love to hear you, because I haven’t seen the latest and greatest, I saw V1. I saw version one of the manuscript. And, I mean, you saw my — I read it with great interest and gave you, probably more feedback than any reasonable person would want.
Dr. Paul Conti: I needed it. I needed that feedback.
Tim Ferriss: It was strong. I’m sure it’s grown and developed. What is the format of the book? Could you lay out the basic structure of the book?
Dr. Paul Conti: You were very, very helpful to me. And the few people that I asked to look over that original manuscript really guided me in the same two ways, which was towards having more of a voice that is, like just the natural voice when I’m maybe talking to someone and I can tend to become a little too academic, right? As opposed to like, look, that’s not how I want to be. So I’m trying to write in a way, or I’ve tried to write in a way that is just it’s plain and clear and thereby hopefully effective. And the other recommendations were about incorporation of stories, of the things in my own life or in my work, which is part of my life that really emphasize the concepts. And that’s what the book is like, it’s meant to be read by anyone and everyone who has an interest in the subject material. And it’s very personalized about me and the examples in the world around me that illustrate the concepts.
And with that in mind, there are four parts to it. So the first is what is trauma and how does it work? So that’s talking about the definition of trauma and the facets of post-trauma syndromes and how they impact people. So the cascade of henchmen of trauma, starting with shame and all the others that come along with shame. So that’s the first part of the book. The second part is the big picture. So that’s the part, that’s the sociology of trauma. Of looking at, look, how is this happening in the world around us? Which, my goodness, has come to a fever pitch with the pandemic and just a spotlight on systemic racism and racial injustice in the world around us.
And also on this erosion of faith in our socio-economic foundation. Can you work really hard and get ahead? How does that work now compared to how it worked 50 years ago? So that’s the second part of it. And in the third part, that’s where it’s sort of called an owner’s manual for your brain. Where I’m trying to really look at how does this work in the brain? What’s the difference between the logic systems and limbic or emotional systems in our brain? How do we find meaning in our memories? How do our memories change when our limbic system changes the emotion tied to memories? How does trauma cascade through mind and body? So that’s the third part of the book. And then the fourth is like how we can beat trauma because again, I do not want this to be esoteric in any way, shape, or form.
The idea is that this is well grounded in the practical of like, what can we do and change now? Which means it has to be, there have to be things that we can employ and that we can employ individually and in small groups of people and then larger groups of people, which brings us back to some things that, well actually the majority of it really comes down to like simplicity. And there’s a common sense to it that I’m advocating for in the fourth part of the book. But I’m trying to use the whole book to get us to the place where like these doable, practical things are really at the forefront of our minds and the person reading the book can feel, I can do those things, I can do them now, and I can advocate for them in the world around me. And that’s what really brings it, the idea that we’re going to have knowledge and the knowledge is going to make change.
Tim Ferriss: Are there any particular stories in the book — I’m sure there are — that we haven’t discussed that have resonated with proofreaders and those who have had a chance to read it? Do any come to mind?
Dr. Paul Conti: I’ll start with — so my favorite story, my favorite part of the book, maybe my favorite story ever in my own life, which I had shared. I don’t know if I will remember, it was a while ago, but you really did like this. And that made me feel good about the validity of it —
Tim Ferriss: I believe it.
Dr. Paul Conti: Because it’s a positive story. Like there are stories that are about how people get to the point where like really bad things have happened, and that’s part of us understanding, but there are stories about overcoming too. And my Uncle Rango, who was such a dear, beloved person in my life, is someone whose early life didn’t look like things were going to go that well. He had a sixth-grade education and not a lot of guidance and support, and then was drafted in the Second World War and experienced some horrible, horrible things during the war.
But through those experiences developed a sense of self that said, “I am a conscientious person. I am a strong person. I’m a person who can do difficult things. And who can do difficult things for reasons that are so strong that one can’t look away from them and a person who can do those things should not feel ashamed of themselves. Should feel a sense of pride amidst the recognition of tragedy.” And even with a sixth-grade education and the limits that kind of lack of exposure to the bigger aspects of the world and even of how our minds work, was able to really understand that and have a very, very good life. And part of why he had a good life was the silver lining of the trauma that he experienced in the Second World War, because he came out of it with a sense of self that said, “You know what? You’re not a delinquent loser. You’re the opposite of that. You’re someone who leads men to safety when they’re otherwise likely to be killed.” Who does — and I won’t sort of give away the story — but does something incredibly difficult that haunted him his whole life, because in his opinion, I don’t understand what else there could have been to do, but what he did, because that was what was in front of him. And he didn’t see it as his fault in a sense that would have brought him shame, if that makes sense. And that’s why I think it’s my favorite story. And even before, when I was younger, I was able to put all this together, I could see reasons that made me feel proud and made me see hope in that. Even when I was quite young, his story was very empowering. Even though we didn’t know the details, he never would tell us the details, but we knew what he had come through and that he was this decorated war hero, and we felt proud of him because he felt a sense of pride in himself.
Tim Ferriss: That’s right. I do remember Uncle Rango. Yeah, I do remember, how could one forget?
Could you speak to, or define, selective abstraction? Because this is a thing that might be worth digging into.
Dr. Paul Conti: Selective abstraction is when we take one detail from a big picture and we construct the story of that whole big picture around the detail. An example, it’s probably a common example, but even in my own life, is like, I can come to work and I can have a good day at work and feel like I’m doing good things and I’m helping people. I generally can feel good about things. But then if I can’t find my keys when I’m leaving and since it’s really happened, and then, I’m frustrated now and I’m frustrated with myself. And when I finally find my keys or I get people to help me find my keys, the narrative that’s going on in my head is like, “What a loser. I mean, you can’t even find your car keys to drive home. What the hell is wrong with you?”
And that’s the story. And then I can get home and my wife could ask me, “How was your day?” I’m like, “Ah, it’s a terrible day because I’m incompetent,” because I built the story of the whole day around what — the salience negative. The thing that triggered in me my own susceptibility to thinking I’m not good enough, and what I’m doing isn’t worthwhile enough and look, what’s wrong with me? And that’s selective abstraction. Because that was probably 10 minutes of my day, but my brain builds a whole story of the day, which is my story of myself, around that negative thing.
Tim Ferriss: Selective attention is a hell of a thing, right? You buy a new car and all of a sudden everyone’s driving the same car, but of course those cars are already out there. You’re just paying more attention now.
Dr. Paul Conti: And that’s so big, because this is all about salience biases. What are we paying attention to? And trauma makes us pay attention to the negative. That’s why we think the world is less safe of a place. Or that we’re less competent people. This is the danger. We use selective abstraction and salience biases and attribution biases, where something negative happens, that I’m going to attribute it to me. And I see this all the time where something negative may happen next door. A person had nothing to do with, but they feel that it’s their fault. Because we get enough of this in ourselves. And we literally forget who we are or what we’re worth, which is why people will stay in jobs that they hate when they could try something different or they’ll stay in abusive relationships when they could end the abusive relationship and not enter another one. Where does all that end up? It ends up in learned helplessness and learned helplessness pushes people towards more trauma and very often towards death.
Tim Ferriss: Could you say more about that, when you say towards death?
Dr. Paul Conti: Because the accumulation of trauma makes people more and more desperate for ways of coping. It’s like, you and me had talked about drug addiction, and we talked about the decrease in role performance and the shame that comes along with it and the stigma, Nobody decides, “I’m going to use drugs because what I want to do is ruin my life.” No one makes that decision. So if we look at, as you were saying, Dr. Maté was saying, “Look at the pain in the person; where did that come from?” And not always, but a lot of times, where drug abuse and drug addiction comes from, it comes from pain and suffering and a desperation to feel different. So more pain and suffering means people are more likely to repeat maladaptive patterns that lead them to more trauma.
And they’re more likely to feel desperate for soothing in a way that can, for example, pave the way to substance use. Because the blind — imagine like a set of blinders that it starts off, they’re outside our peripheral vision. So they’re not affecting us at all, but as time goes on, they can encroach more and more and more, as a person has more trauma, less healthy coping mechanisms, a more negative view of self, a more negative view of the world, and then the blinders come in and at some point the blinders are so narrow that all the person sees is basically a helpless and hopeless picture. And that’s where a lot of suicide comes from. And where a lot of accidental deaths come from. So often the goal is, when I think about what are we doing in trauma treatment, and the image that’s in my head a lot is, we’re trying to take those — I imagine a set of blinders, a person who’s just peeking through with one eye, and we’re trying to pull them out so they see the breadth of truth.
The breadth of their perspective allows that person to again, see truth, and remember — oh, like an example. I absolutely understood at one point in time that violence is not acceptable in my life. I understood that. And I don’t believe that any less now than I did then. But, boy, I kind of forgot it in the middle. Because the person forgot that they could have a life free of violence or that they deserve a life free of violence. That’s where this narrowing of blinders and the change in emotion and how emotion impacts our memories, and tells us what our memories mea. The memory of something happy with other people can go from being a memory that says, “Right, I can do anything, and I can interact with people, and they like me, and want me to be around,” to a memory of something that’s impossibly lost for the person. And again, that’s not true, but if you see it as impossibly lost, it is, unless there’s some process that leads you to a place where you remember what’s true, that you forgot.
Tim Ferriss: This brings to mind for me one tool in the toolkit, and it’s more of a category, but it’s one I would love to hear your current thoughts on. I do think, and I’ll get to the punchline in a second, that it’s very dangerous to view anything as a panacea or a fix-all of any type. And it’s particularly common with what I’m going to mention, which is psychedelics. But as we’re talking, if we, for the time being, include MDMA in the category of psychedelic, just to make it a little easier to discuss, even though one could argue it doesn’t cleanly fit in that category. But as an empathogen, it is remarkable to me how patients, say, going through the MAPS trials, phase three trials and so on, can recontextualize memories that, for decades, have had a fixed emotional tenor.
And suddenly they’re able to go back and with a decreased fear response, unwrap that memory, recontextualize it as an adult with better coping mechanisms, and sort of re-install it, so to speak. It’s really a fascinating, replicable phenomenon for a lot of patients. How do you think about, if you do it all, psychedelics, their use, abuse, roles, misapplications, what is your current thinking?
Dr. Paul Conti: My understanding from the research, the really consistent reports, tell me that there’s something immensely powerful here that has the capacity to do an immense amount of good. But we have to be careful with anything that’s even moderately powerful, let alone very powerful. And that we’re figuring out how to deploy these kinds of tools to do something amazing. And I say that in like the full meaning of that word. Because what they seem to be able to help people do is to look at trauma from the perspective of truth without the reflexive shame. that’s: “If someone else hurt me, what’s wrong with me? Why am I being hurt?” Like that’s the reflex, and it generates shame. Imagine how our perspective is already immediately altered. If trauma arouses shame, then the trauma itself immediately alters our perception mechanisms that we can use to understand the trauma and navigate our way through it.
And I think that goes hand in hand with this idea that, we value so highly, as human beings, the outer parts of the cerebral cortex. The parts that are uniquely human. The parts that let us, for example, have a language. And the five senses, which I know, I understand they’re not uniquely human, but these are the parts, though, of the outer cortex of the brain, our ability to plan and to project into the future. And we value these so highly, but we do that in a reflexive way. Why do we value that? Just because the end point of the cortex is the farthest the brain is grown outward. That’s the part that abutting up against our skulls.
But like, we don’t do that with roads. I don’t say, if a road is going somewhere I want to go, that, “Oh, but it’s better to keep going. Maybe that road dead ends in a muddy place I can’t get out of.” What may be happening is that there’s a brain stem — that’s the earlier part of the brain, the first part of the brain that’s about the basics of survival. Temperature regulation, sex drive, appetite. And then, at the other end of the spectrum, there’s the cortex that is about the things that we need in order to sort of keep us alive. And that may be like what the five senses are about, for example. It’s about, in a sense, vigilance, and it’s about keeping us alive. And that’s important, but it may be that the brain stem, which is about just staying alive, and the cortex, which is about staying alive in a different way — by monitoring and navigating our environment — are less interesting than what is in between.
So that’s where the amygdala is — Grand Central Station for negative emotion and the emotion that impacts vigilance. The hippocampus, which is about memory, what’s the hippocampus connected to? The amygdala. So the limbic system and emotion is so important to how we remember things and the meaning we put in memories, and to the insular cortex, a part of the brain that it may be that the insular cortex is really about life lived or life felt and understood, and that these medicines along with psychotherapeutic tactics can do this too.
And judicious use of standard medicines can help do this, where we’re living more in the part of the brain that can actually understand and assess what life is about. And it may be that the psychedelics altering the Default Mode Network and changing how the brain is communicating, where the seat of the brain’s existence consciously and unconsciously is at, opens up the ability to get out of the cortex and into the part of the brain that says, “Gosh, something terrible happened. What is that and what does that mean?” Without all the reflexive loading of guilt and shame, the million thoughts we may have had that can perpetuate guilt and shame and the narrowing of perspective.
Tim Ferriss: That’s an excellent way to put it. It’s almost as though, before we consciously think about trauma, for many of the people who have suffered trauma, if not most, there’s almost a bootup sequence in the background, which is what you’re about to think about or talk about was your fault, because you’re flawed, colon, and then you have — and if that is the canvas upon which all subsequent thoughts are painted, you can predictably experience a very challenging interpretation of yourself and of events.
Dr. Paul Conti: The thing gets reinforced. Because that challenging interpretation gets reinforced the next time you think about it and the next, and the next, and the next.
Tim Ferriss: And you talked about the Default Mode Network. I mean, this is obviously a topic, sometimes a controversial topic of conversation among the neuroanatomists and researchers looking at psychedelics. There are a number of aspects also that as we’re talking are of great interest, and of course a lot more research is needed to delve deeper and even confirm the sort of therapeutic implications of what I’m about to say. But one is sort of bottom up, which is neurogenesis. So if certain psychedelics like psilocybin is found in psilocybin mushrooms or synthesized for that matter has neurodegenerative effects in places like potentially the hippocampus and elsewhere.
And at least anecdotally seems to have some effect on TBI in veterans, for instance, is it plausible that any type of sort of neuronal and you’d probably be able to speak better to this than I would, but more eloquently certainly, any sort of chronic damage or atrophy or mal adaptation from a neuronal perspective from chronic depression, also respond favorably sort of bottom up by bathing in some of these compounds for a period of time. I do think it’s quite likely that there’s something there from just a mechanistic sort of neuronal perspective. The other is that as we’re talking about this overlay of I, as we talk about or think about trauma, when you have hypothetically, let’s just say decrease in activity in the Default Mode Network, and certainly if you experienced ego dissolution in any capacity where the entire sort of skin encapsulated concept of I begins to loosen its grip on your perception, if you then revisit trauma, if there is no I or less of an I, it becomes harder to blame yourself, if not impossible for what you are witnessing.
So you have the ability also to become an observer who is not just less prone to self judgment. This isn’t always the case, but in some instances you are incapable of self judgment and it’s very peculiar, but certainly in the reports out of say sessions from Johns Hopkins and elsewhere, it’s remarkable to see what these compounds can do. And it’s very tempting to view them as the holy grail, which will solve all of our miseries and pains. And I think that is, I feel like I’m talking too much, but I’ll finish in a second, that it’s very tempting with anything new to overestimate the applications. And some early studies can also seem to overstate the efficacy. And this is seen in medicine and psychiatry over and over again.
I wanted to ask you, we can come back to this topic, of course, because my listeners know I’m happy to talk for hours about this. But I’m curious on, let’s just call it more conventional side. And with the caveat that we are not providing medical advice, I am certainly not a doctor. I do not play one on the internet, but this is for informational purposes only. And it’s a conversation between you and I. In the case of say hypervigilance, because within the conventional pharmacopeia, there are incredible drugs available. And Western medicine, despite the tendency these days for a lot of folks to poo poo Western medicine, I mean, it is the most effective healing system ever devised by humankind, full stop. And I’m curious, so within that massive list of options and all of the available options, what are some of your preferred options and feel free not to answer this if you don’t want to, but if we were looking at a case, say of hypervigilance and you wanted to put someone on a short cycle, or I should say, a finite cycle of a compound or compounds, what are the top of the list and how do you go about selecting for someone?
Dr. Paul Conti: Sure. Maybe I’ll come at this by saying, the first thing to say is we have all these arrows in the quiver, and the empathogens are potentially these new, wonderful arrows in the quiver, but we need to understand them. And there can be a tendency to overestimate benefit and underestimate risk. So there’s research going on that says that these can be just fantastic tools in the quiver, but we need to understand them better. And as that research is coming along, what I believe we should also be doing is looking at the arrows we already have in the quiver that we are not utilizing effectively. And that includes all the psychotherapy modalities that get underutilized, because we’re just taking inventories of symptoms and trying to treat a symptom and call it good. The same is true of medications, that if we’re really paying attention to people and to what’s going on in them, we can then actually target symptoms, but we’re targeting symptoms and understanding what the big picture is like.
Tim Ferriss: Right. Exactly. There’s a purpose, there’s an outcome beyond suppression, or there’s a target, there’s an intention beyond just alleviation of symptoms.
Dr. Paul Conti: Right. So if you told me that now, after the tragedy that you learned of, that you’ve an increased sense of tension in you all the time, then I would look to maybe an SSRI kind of medicine, a medicine that could improve your distress tolerance, because that extra tension is in you all the time. If you said, “No, it’s actually only in me when I’m driving and I’m getting a little tremulous and I’m sweating,” we might think about another medicine that can block the impact of that extra tension on you physically, because that’s reinforcing. And then you get into that mind-body, body-mind vicious cycle.
Tim Ferriss: What class of drug would that be?
Dr. Paul Conti: A beta blocker, for example, would be a possibility in that scenario. Or if you told me, “Everything is okay, but I’m really having trouble getting to sleep, because I can’t get this out of my mind.” Then I would not suggest a sleeping medicine because I would think there’s nothing wrong with your sleeping system, but sleep is being blocked because your distress system is amped up. And when your brain’s trying to sift down into a peaceful place, that’s the time that the intrusive thoughts about this new trauma come into your mind.
So can we use something that in a time limited way, like right around bedtime, decreases the distress signaling in your brain so that you can fall asleep, as opposed to a heavy-handed intervention, which we’d say, “Well, let’s put you on some sleep medicines,” when it’s not really your sleep system that’s broken, it’s your distress that’s higher.
Tim Ferriss: Just because I love the details of this kind of thing, what class of compound or drug might fit that last example, the distress signaling prior to bed?
Dr. Paul Conti: This is one of the interventions, and it may actually be the intervention, I’ve got to think hard about that, that has the most success. If not, it’s in the top three, which is using medicines that are called anti-psychotics, but that’s a terrible name. It’s like, just because these medicines are — just because they’re used for that doesn’t mean that’s all that they do. It’s such a misnomer to name something by what its first use is. I don’t call a dollar a baseball card buyer, even though that’s probably the first thing that I bought with a dollar. So it stigmatizes the medicines. And then they don’t get used for this, but low dosing of those medicines blocks what are called D2 receptors, blocks receptors that are around distress transmission. And very low dosing is often immensely helpful in situations where there’s a lot of distress signaling and that’s impacting sleep.
So I can’t count the number of people I’ve seen who can’t sleep. And they’ve tried quote-unquote, every sleeping medicine. And sometimes they actually seemingly have, but they’re not going to sleep then because to say, “Oh, they have a sleeping problem,” is just pointing out the obvious, that they’re not sleeping. That’s not a medical conclusion, but to point out their sleeping system isn’t broken, hence no impact from the 15 sleeping medicines, but their distress signaling is now increased because of some new trauma or triggering of an old trauma or vicarious trauma, then we can solve that, often very readily.
And that leads back to, you were talking about the empathogens and the idea of neurogenesis. And it may be that neurogenesis is very helpful in certain parts of the brain, it may be that neuronal pruning is helpful in other ways, too. What we’re really trying to understand is what positively impacts connectivity. And that may be neurogenesis in certain parts of the brain, but it may be changing balances of neurons and maybe it’s neurogenesis of inhibitory neurons.
So things get complicated enough that how we can look at that though, in a practical sense, because we’re not the core neuroscientists. How we can look at that practically is saying, what we’re trying to do is alter brain connectivity, whether we’re using psychotherapy or a hug to a person that you care about, or we’re using medicines, or we’re using Western medicines or pathogens. What we’re trying to do is change the sequence and patterning of brain connectivity from one that is stereotyped in a negative way. And like you said, that reflexive shame, ones that primes the audience before the curtain goes up to say “The play’s going to be bad and you’re going to hate it.” So when we shift that, we’re really shifting connectivity and that’s how we can see old things in new and true ways.
Tim Ferriss: What’s so wild also, and these are just occurring to me as we’re talking, what’s so wild about some of the empathogens and also certainly psychedelics, many psychedelics is the phenomenon of hypermnesia. I mean, where you will be able to recall the say, in my case, for instance, the brown corduroy on the couch when I was two or three years old, and immediately recognizing that that is a real memory. I have photographs, I can go find them. I just haven’t seen them in decades. And it’s really remarkable. And it’s so easy with neomania to focus on, even though many of these compounds have been used by humans for millennia, they are new in their popularity as it exists today. And it’s easy to discard things that could be very, very effective, either as monotherapies or perhaps even in tandem, Although you have to be careful, obviously, with combining things.
When we take a look at the anti-psychotics, since that’s not at least categorically something I’m familiar with, what are some of the frontline anti-psychotics, what are the compounds and the names? I’m just wondering if there are any I would recognize.
Dr. Paul Conti: There are probably two dozen or so of these kinds of medicines. The ones that are very, very potent for actual psychosis are in general, not what we’re using. There are some older medicines. So even chlorpromazine, which is — it’s the generic name of Thorazine.
Tim Ferriss: I was going to say, Thorazine is probably the only one that I’m familiar with.
Dr. Paul Conti: It’s been around. That’s the first one, it’s been around for somewhere around 70 years now. And it’s what’s called, it’s a low potency medicine, meaning that it doesn’t block those receptors very much, but even a little bit of blockade can make a huge difference. So a medicine that was used in like 800 milligrams, 1,000 milligrams to treat psychosis, very often, 25 milligrams, 12 and a half milligrams, maybe 50 milligrams can decrease the distress signaling enough that the rumination at bedtime, the distress that causes so much misery then can go away. So it’s the example, I would say, because in low dosing, it’s overall, everyone has to make their own medicine decisions with the person prescribing to them, but it’s overall a safe and low side effect medicine at low dosing and often remarkably, remarkably effective. So that would be the one that I would really highlight.
And I think then, we’re decreasing the distress signaling, which creates stereotyping of our thoughts and feelings. If we’re thinking the same thing over and over again, and then think about how that would predispose to blocking memory. I mean, if you think of prior trauma and there’s a reflex, and immediately feel shame and responsibility, “Oh, my God. How did that happen? How did I let that happen?” All those things that we beat up on ourselves, how are we going to remember details? It may be that the connectivity changes in more peaceful states of mind, which could be through an empathogen or not. Again, the research is bearing that out, lets a person know and remember and understand more, because that’s not blocked by trying to have calm thoughts in the midst of a hurricane. You’re more likely to have calm thoughts in the midst of a calm setting. And as important as that is outside of us, it’s got to be at least equally important inside us too.
Tim Ferriss: Absolutely. In what category does lithium belong? Because I’ve also read quite a lot about, I suppose, as a monotherapy for something like, and please fact-check me, on something like, I want to say bipolar, but maybe I’m getting — we’re looking at 1,500 milligrams or something like that, but I was sent some reading related to a very low dose and there are different types of lithium. There’s lithium carbonate, lithium orotate there are many different forms, but of really low dose, like 5 milligram, 10 milligram pre-bed. And I’m wondering if that plausibly would have any similar effects or if it’s exerting its effects differently. I’m not familiar with how lithium works.
Dr. Paul Conti: The most helpful way to approach lithium as being two entirely different medicines, depending upon dosing. And maybe an even better way to look at that is a medicinal dose versus a supplement kind of dose. So lithium in high dosing is a very effective medicine for bipolar disorder. And there are a lot of medicine choices now, so we can nuance that to try and minimize side effect and get a very effective medicine regimen with low side effect. But for a long period of time, there weren’t a lot of other medicines and then high dose lithium monotherapy was what happened most of the time for bipolar disorder, which can be, is often very effective, but has a lot of side effects. That’s lithium as medicine. And that’s also a reason lithium often has a stigma around it, because it was used for bipolar disorder in a way when we didn’t understand as much about it, oftentimes the illness was out of control by the time it was treated, which can happen now, but it was more so the case then, so that led to lithium having a stigma around it.
But everyone has lithium in them, to some degree. We all do, as human beings. So there’s lithium in all of us. And what seems to be the case, and again, it’s hard to do great studies about this because it’s just so big to try and do, but what seems to be the case is that more lithium, including more lithium in the groundwater. So small amounts of lithium, but that are lithium that are higher in all of us seem to sort of make everything better. It seems like there’s less depression, there’s less violence. There may be less dementia. And one could think of putative mechanisms, if you think through how lithium impacts ion channels in neurons in the brain, we can think of how that might make sense, but we don’t know that for sure, but what we do see, and I’ve seen this over and over and over again, is that in the right person, and again, you have to be guided towards it because there could be side effects from it and it can negatively interact with other medical conditions.
So if a person is getting the medical guidance to safely take low dose lithium, that often in a way that really is looking at it like a supplement, can often be very helpful to the person, including an increased sense of calm, an increased sense of peace. So for mild problems around sleep, a little bit of lithium can be very helpful for bigger problems. Once a person is getting ruminative and really can’t sleep, and the cat’s out of the bag and it’s going over and over and over again, then usually, we are then beyond where a supplement of lithium is likely to be helpful.
Tim Ferriss: Lithium is fascinating to me.
Dr. Paul Conti: I agree.
Tim Ferriss: I recall at some point being sent a piece, it’s an older piece. I believe it was in The New York Times and the headline was something like, Maybe We Just All Need a Little Bit More Lithium. Now, understanding the limitations of observational studies or, what you can do by torturing the data. I understand the shortcomings when something isn’t controlled and placebo-controlled and randomized and so on. Nonetheless, I recall this piece pointing to groundwater levels of lithium and there being an inverse correlation of hospital admittance related to homicide, suicide, psychosis, et cetera. And at the very least, I found it very thought-provoking.
How would you think about, for instance, and I know this is a little bit of inside baseball, but I am so endlessly fascinated by all of this. And I’ve heard very mixed things, but trazodone is a sleep aid and maybe you could speak, explain what that is. My understanding is that it is an SSRI, but that it was never effective as an antidepressant because people just fall asleep and therefore, but like many drugs, in our pantheon, was repurposed for sleep. I don’t know if that’s accurate, but I’d love to hear your opinion.
Dr. Paul Conti: Sure. First thing I should say, in the interest of full disclosure, I think I’m the person who sent the lithium article from The New York Times.
Tim Ferriss: You know what? You might’ve sent it to me or you might’ve sent it to Peter.
Dr. Paul Conti: And Peter sent it.
Tim Ferriss: Right. Of course. Of course.
Dr. Paul Conti: So I want to say, whoever sent that article was brilliant and prescient, but no, it needs the full disclosure. I think it was me because I do believe in that. I mean, as you said, it’s very hard to do these population studies, but there is some good data that points us in the direction of all that being true and to the very low risk of low dose lithium. So then you have a higher likelihood of a benefit, you have a high likelihood of some benefit with low risk. So that being said, the trazodone question specifically is, yes. So trazodone was found to be so sedating for most people. And it seems like there’re probably some genetic idiosyncrasies, because some people don’t find it sedating at all. So there’s probably just some idiosyncrasy there, but most people find it very sedating, which obviously works against the use of it as an antidepressant.
But what was found is it’s actually quite a safe medicine and again, we want it to be prescribed and there are some risks to it. It’s not entirely safe, but by and large, with appropriate prescribing, it’s quite a safe medicine that often is sedating enough that it can really be helpful to people for sleep. So when it doesn’t work or if the dose has to be too high, then it’s sedating, it makes sense to shift away from it. But it’s a good tool to have, or a good arrow in the quiver, pharmacologically, because it does help a lot of people with little to no side effect, you’ve got to get the dosing right and see, can the right dosing for sleep be also non-sedating enough for that person so they don’t have a hangover from it essentially the next day?
Tim Ferriss: Is there any, I suppose this is true with just about anything, but, addiction potential with trazodone, can it be physically addictive or is it more so a psychological risk if any?
Dr. Paul Conti: Yeah. There could be a psychological risk, because anything that we’re sort of leaning on, so to speak, to some degree we can really habituate to and come to rely on, but that’s different than the mechanisms of physiological addiction, which aren’t present in trazodone.
Tim Ferriss: Wouldn’t apply. What does the D in D2 stand for in the receptor that you mentioned with respect to, I believe it was the anti-psychotics?
Dr. Paul Conti: Dopamine. Dopamine. Yeah. Dopamine is like a currency. People say, “What does dopamine do?” It’s like saying, “What does a dollar do?” It depends on where we’re spending it. And in these particular circuits, dopamine then becomes a currency of distress. And if there’s enough of it, a currency of psychosis, because sometimes people think of dopamine is pleasure, so why are we doing anti-dopamine things? In these particular circuits, that’s not what dopamine is buying, it’s a currency of distress and we want to play that down.
Tim Ferriss: Ah, man, I could talk to you for hours and hours. We’ve done it before.
Dr. Paul Conti: Thank you.
Tim Ferriss: Yeah. I find it so, so endlessly interesting. And what makes it also so fun to spend time, one of the additional reasons it’s so fun to spend time chatting with you is that you are not isolated in an ivory tower working with hypothetical cases. People come to you for help and solutions. So you are an active clinician who is working with real patients.
I have a note here and I’m definitely going to need you to help me elucidate this, but stress-diathesis model. Am I saying that correctly?
Dr. Paul Conti: It’s stress-diathesis, which also gets called a vulnerability stress.
Tim Ferriss: Diathesis. Oh, boy. I knew I was going to fuck that one up.
Dr. Paul Conti: It’s one of those words we like in medicine because it sounds smart, but all it really means is a genetic vulnerability, which is why that’s also called a vulnerability-stress model, which means we all have genetic vulnerabilities to certain things. Because you might be, depression for me and panic attacks for you or vice versa, that our genes give us a predisposition towards. And then the stressors. So that’s, say, maybe the nature of it, but then the nurture part is what can bring a potential problem to the forefront. So you think about a post-trauma syndrome. We’re all protected or vulnerable to different degrees, say at conception, based upon genetics. Now, we don’t understand that fully, but we know we have different risk profiles and then it’s the stress or the nurture part of it, what we experience in life that can determine what comes to the fore.
And this is also where the multiple hit hypothesis of post-trauma syndromes comes to the fore, that it may be that something really traumatic happens to a person and they don’t have a post-trauma syndrome. Then something else happens, then something else happens. And we might think, well, they’re pretty genetically protected, but the stress can take its toll where maybe the third, fourth, fifth, sixth hit, even if it might be a relatively minor one, compared to those that came before it now create a full-blown post-trauma syndrome.
Tim Ferriss: You know, we could go in a million directions. Outside of your book, which I’m going to mention again, are there any particular resources that you might recommend for people who are interested in learning more about trauma from credible sources?
Dr. Paul Conti: Sure. I think NAMI, which is present throughout the country, it has local branches throughout the country, N-A-M-I, that NAMI can be extremely helpful. We can often find resources and have links to it.
Tim Ferriss: What does that stand for?
Dr. Paul Conti: NAMI is the National and here’s where I first have to pause and check, because I don’t want to get a word wrong. National Association or Alliance, you know what I mean? I don’t know what the A, let me just, maybe we’ll start that again, but let me — it says National, I knew there was something a little bit, it’s the National Alliance on Mental Illness. That’s what’s [inaudible 01:49:57] it’s on. So maybe do you want to [inaudible 01:49:59] start again?
Tim Ferriss: Yeah, sure. Yeah, go for it. I’ll ask you again. So what does NAMI stand for?
Dr. Paul Conti: So NAMI stands for the National Alliance on Mental Illness and NAMI often has resources and links to support mechanisms in the community. And I think can be very, very helpful. The book The Body Keeps the Score by Bessel van der Kolk is also a very, very helpful resource. Anything that helps a person to find some inner peace inside of them. Something that takes away from the swirling inside of us that can happen post-trauma and the swirling from the social circumstances around us, anything that helps us get away from what’s keeping us in the same loops that lead us further from truth, whether it’s the truth of our own trauma or the truth of the trauma going on in the society around us. The response to the pandemic, the impact of systemic racism, the erosion of faith in our socioeconomic model, these can be seen [crosstalk 01:51:04].
Tim Ferriss: Existential distress related to climate change and things like that, for instance.
Dr. Paul Conti: Right. These things can all be seen through a political lens and because they get politicized, it takes people away from actually looking at, what’s really going on here? How is it impacting how I’m thinking and feeling? What’s the truth of all of this? Anything that takes us away from getting lost in the politicizing of things and more towards the apprehension of the true existential nature of these things.
So there are a lot of helping resources and things that we can do to get us into a calmer place inside. And I know that’s a kind of a non-specific answer, but there’s so many routes of proceeding towards that, that I want to mention that too.
Tim Ferriss: Absolutely. Paul Conti. Paul Conti, Dr. Paul Conti. C-O-N-T-I.com, pacificpremiergroup.com. We will link to all of these things, everything we’ve mentioned in the show notes. The new book, which I highly, highly recommend everybody pick up, take a look at it, get it for people who need it, is Trauma: The Invisible Epidemic, subtitle, How Trauma Works and How We Can Heal From It. I am such a fan of yours. I don’t say that lightly. We’ve spent real time together. I’ve seen the results of what you do. You are an in-the-trenches practitioner. And I’m just so glad that your work, you personally, and this book are going to be available to more people. So thank you for —
Dr. Paul Conti: Thanks so much, Tim. It means a lot.
Tim Ferriss: — taking the time. Absolutely. Is there anything else you would like to say or any request of the audience, any suggestion, anything at all that you would like to say in closing comments before we wrap up for today?
Dr. Paul Conti: I think the one thing I would say is that our lives and the world around us can seem to us to be very helpless and hopeless, at times. We can feel helpless and the world can seem hopeless. And that’s not the case. I cannot describe the number of people I have seen, worked with who feel that way, and really are at risk when they’re feeling that way, and come out to a different place. That if you’re feeling that way, that probably means that those blinders have closed in, and closed in, and closed in. And there is help for that. There really and truly is. And if you’re not getting help the first, second, third time, keep trying. There’s help there to be had. And it can make just such a difference, because the narrowed blinders represent a risk to us that comes from trauma and that we can absolutely do something about and change.
Tim Ferriss: Perfect place to wrap up. And so nice to see you, Paul, and —
Dr. Paul Conti: Thank you. You too. Thanks so much. It was fun. I knew that it was going to be fun.
Tim Ferriss: — yeah, yeah. absolutely. Yeah. This was a really, really enjoyable conversation, very dense. To everybody listening, once again, I will put links to everything we talked about in the show notes at tim.blog/podcast. You can just search Conti C-O-N-T-I, and it’ll pop right up.
And until next time, be safe, be aware of blinders, we all have them. Pay attention to your stories because you are the author, not just the reader of those stories and they craft your reality. And as Paul said, you are not alone. This is part of the human condition and there are people and tools and help available. And there are things that work. So thank you for being here, Paul, and thanks everybody for listening.
Dr. Paul Conti: Thank you for having me.
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