Hey everyone, welcome to the Peter Attia Drive. I'm your host, Peter Attia.
To drive as a result of my hunger for optimizing performance, health, longevity, critical thinking, along with a few other obsessions along the way. I've spent the last several years working with some of the most successful top performing individuals in the world. And this podcast is my attempt to synthesize what I've learned along the way to help you live a higher quality, more fulfilling life. If you enjoy this podcast, you can find more information on today's episode and other topics at peteratiamd.com.
Welcome to this week's episode of The Drive. My guest this week is one of my dearest friends, Dr. Paul Conti. Paul is a brilliant psychiatrist. In fact, I often refer to him as the single best psychiatrist I've ever come in contact with, and I've met some many very sharp people over the years.
I've long wanted to have Paul on the podcast. I've always wanted to interview Paul just in general because there's not that many people who I find myself having discussions with. And I think to myself, how can this discussion be shared with others? And throughout this interview, you'll hear us even comment to that effect, which is God, it's almost like we're not even talking in front of microphones. This is exactly the kind of conversation we find ourselves having so often.
Paul's a very special person. He doesn't get into great detail, but his life has been shaped by a number of really, really tragic events, a couple of which he alludes to here, many of which he does not. In fact, some of the most tragic events in Paul's life, he does not allude to. But I think the point that comes across here is that Paul is one of the most empathetic, kind, giving individuals
And his understanding of the human condition is really unparalleled. So, in keeping with one of the general themes here, which is longevity, of which health span and happiness are important components, we go really deep on this topic. We talk about what is meant by trauma. Many people just think of trauma as, you know,
got hit by a car or something like that but we get really into emotional trauma. We talk a lot about shame which is the result of trauma and what it ends up doing we talk a lot about depression, suicide, and a number of other topics that are closely related to this. I
I do think at times this is a little bit heavy, but we really don't get into any of the technical stuff that I thought we might get into in large part just because I think there was so much to talk about without getting into the neurobiology. I do think that Paul and I will need to sit down again in the future and get a lot deeper on some of those other topics that I also thought.
you know, would be interesting and I suspect a number of you will find very interesting. So again, this is not a deep podcast from a technical standpoint, though we do get into some of the heavier stuff. Unfortunately, Paul is not someone you're really going to find much about on social media. Paul is someone whom can be contacted through his office, of course, and will provide that contact information for folks who do want to reach out to his office.
but the good news is paul is really considering writing a book and after we finish recording this podcast we spent another twenty minutes talking about. The book he wants to write and the just of it is the book is exactly about the stuff we talked about today so i couldn't be more encouraging of paul doing this and i i think that the world will be a better place for that so.
I hope you enjoy this episode half as much as I enjoyed listening to Paul talk about all of these things and I think almost anybody will find something of great value in this episode. Hey Paul, how are you man? I'm doing well Peter. Thank you for having me. You're a super trooper here. You have laryngitis. I do indeed have laryngitis. I am persevering and I appreciate your patience in persevering with me.
Well, luckily, I guess luckily is the wrong word, but most people here don't know what you sound like normally. So they probably won't even know that you're that I'm only bringing it up because I know you're straining a lot to speak. But this is such an important topic. We didn't really want to put it off between the two of us were so busy, even though we're in New York off and that we could both have a night when we don't have something else to do, I think makes this worth it. So thank you.
It's my pleasure. And even though I sound like the godfather, I'm still going to do my best to come across as open and honest in a way that's not quite consistent with the godfather. Although you did pull one old school Italian trick a moment ago, which was as you came in my apartment, you'd be lined for the kitchen. What did you do with the aspirin? I gargled with hot water and aspirin, just like my grandmother told me to do. She gets credit. If people can understand me, credit goes to my grandmother.
All right, so there you have it, your first old Italian old school trick on what to do with laryngitis to take some boiling water, smash some baby aspirin into it and gargle it. They didn't teach us that in medical school, but I'm still doing it.
All right, so speaking of medical school, you and I have now known each other for 21 years. Amazing. Yeah, almost exactly 21 years. And I think the relationship that you, me and the other five coconuts had in our med school class, the seven of us, probably in some ways really annoyed most of our med school classmates because we were, we became close like within the first week of school and never separated. We were just, we were an inseparable group of knuckleheads that I strongly agree that that annoyed people.
Yes, yeah, yeah it did. But we're fortunate and I feel blessed to have met all of you guys and in particular probably all of the seven of us now I think you and I by far spend the most time together because so much of our work clinically overlaps.
I don't want to go deep so soon, but I think I feel like I have to. So I'll never forget the first day we met. All med students on day one are sort of nervously talking about why they're here and blah, blah, blah. And truthfully, most med students don't really know what they want to be when they grow up. They have sort of figured out they want to be doctors, and that's about it.
but there were some of us that knew i wasn't really one of them i kind of knew i wanted to do something in oncology i thought at the time pediatric oncology one of our buddies decided on day one he was a plastic surgeon and that's exactly what he is today. You said the most interesting thing i'd ever heard which was that you wanted to be a psychiatrist and i just remember thinking i didn't know people went to med school to become psychiatrist i thought
That was sort of a lifestyle choice that they made later on or something like that. But you were adamant about it. Why was that the case? I think it represented a search for truth. I think it represented a search for truth and probably a response to some of the difficult things in my life.
and to a lot of the dissatisfaction that i was feeling with achievement with my personal life my professional life from top to bottom there was a sense of wanting to understand things more and i think it's interesting you talk about how quickly you know this group of us became really fast friends and i think
There was a commonality there that we'd all had some life experience and in different ways as we came to learn, we'd all really been through a lot. And I think we were coming into medical school searching for something and trying to find that something for ourselves,
Through doing things that are good for other people and and I understand that the idea is that's why people go to medical school and I'm not saying other people weren't doing that right but we'd all been through a fair amount and I think it's the the suffering component that drove the ability to maybe be open and honest earlier with one another and to
form bonds that were based upon the searching that we were all doing that drove all of us right to change career to do something different than what we might have thought we were doing as a response to an internal need and I think ultimately as a response to trauma.
It's interesting you bring that up. I mean, I always knew this, but I guess I sort of forgot until you re-primed it. None of us were pre-meds and all of us were a little older. We were all a couple of years older because we'd all in some cases like, you know, in Bobby's case, I mean, Christ, he'd been a mountaineering instructor for a decade or something like that. You know, Zali had been in the army for four years, same with Jason, all these guys, sorry to be calling all our boys out here on the show. But yeah, none of us had just come through.
Right. And certainly people can go through a lot by the time they're out of infancy. So it's not as if people need to be out of school, do different things in order to really gain life experience. But I think the choices that each of us made were choices that came from a place of drive and ambition.
But ultimately that we're colored by very personal things. And I think led each of us to really want something more. And I think we came to medical school in part to find that. And I don't think that there's a distinction between what are the things that we do for other people and the things that we do for ourselves. I think that that's a false dichotomy that follows through Western logic.
that things have to be one thing or another. And I think often the best things that we do for others, we do in a search for some healing or soothing in ourselves. And I think that that was part and parcel of all of us. It was part and parcel of many people that you and I went to medical school with trained with.
But I think it's what made the seven of us fast friends and I think it's why there's remained a strong bond in part because that searching and that desire to do for self through doing for others I think really hasn't changed.
So what were you doing before medical school? In other words, you studied, you were an undergrad and you went to Penn, you studied math, and then you moved to New York. You were working in finance, right? Yeah, I minored in math. I majored in political science. And I studied a lot of history and a lot of literature.
And what I didn't realize was that the attraction to me of everything that I was studying was really the allure of people. I studied World War II a lot, and for a while I thought I wanted to go to grad school and be a World War II historian, and at some point I realized what fascinated me was the people, right? The people who were driving the action, good, bad, or otherwise. The people who were caught in the crossfires, the millions of people who
were part of that event. And what I realized over time was that there was a commonality of drive about understanding what was leading people to do things or how people were responding to things. And oddly enough, it may seem odd, but I think math is kind of part of that too, right? That there are things that happen inside of people and there are aspects of our choice.
Our choice is that we design with a certain linearity, but ultimately, there are complex functions in all of us that make things that we might think are predictable, very unpredictable. And I only kind of realize that in retrospect. I mean, when I graduated from school, I said, I really wanted a good job.
And I came out in 1991, and there was a little bit of an economic downturn, and I was fortunate to get a job with a good consulting firm. And I just thought, OK, that's where I'm going to go, that I'm going to have this business career. And if it's with my father having been entrepreneurial and had a business career, and I just thought, OK, that's for me. And I'm going to make my way doing that.
so then what changed what changed is it really really did not make me happy and i say that with no criticism respiration whatsoever to people for whom it doesn't make happy but there was something very much missing from it for me and and i think that was the intensity of human interaction and so the intensity of human struggle and
What I found is, you know, I did that for four years and I took some time in the middle and I traveled for several months because I was kind of trying to figure something out, like why am I not happy, right? And I came back and I took a better job with the same company, right? So as time went on, you know, I had more authority. I was making more money. I was doing more interesting things and I was less happy.
And it really became quite stark to me that unless I was delving into like the intensity of what's going on inside of people, I wasn't going to be happy. And I think, you know, what I didn't really fully realize was that that was going to be a way of kind of delving into the things going on inside of me. And I mean, as you know, and I've talked about many, many times,
There were some traumatic things that happened during that time that really just brought to the fore to me I want to understand better and I want to be able to help soothe things in other people and what I didn't realize at the time was that wasn't a way of saying oh I'll be selfless and you know and altruistic right and like that's gonna save the day for me but
But really, that also, what I didn't realize at the time was the mirror that it would put up that would allow me to just get access to help that I didn't have before be open and communicative and understand myself in ways that it wasn't necessarily programmed to do. I was programmed to work hard, achieve, not be weak. And that inability to express, even to myself, let alone to other people, was ultimately draining the life
from me and actually did drain the life in terms of actual death from some people around me that I very much cared about. And in some ways I was rebelling against that way of being in the world and that way of teaching people to be in the world. And I had some, I think, inkling of understanding of that, but it more came through anger and rejection of things and it came through an understanding
through the lens of compassion that we've kind of structured our society in a way that makes it very, very difficult to live in.
You're alluding to, obviously, something I know is very difficult, and we've talked about it a lot. I don't know that we need to necessarily go into great detail here, but in the span of a year, if I recall, you lost your brother and your best friend. Yeah, my brother died by suicide, and about a year later, one of my closest friends, or the same, a close group of friends growing up, sort of like we had in medical school where there were
a group of us, and one of those very, very close friends from childhood also died, and he didn't die by suicide, but there was sort of that same kind of desperate recklessness that I saw this common root in those two deaths, and they confused me and infuriated me, and made me feel very helpless and vulnerable.
and wanting to be able to understand better and to fight against this thing that made it so hard for people to get help and to be vulnerable and that was really the commonality is like both of the people who died
had real and significant needs inside of them that came about naturally. Like something you want would never criticize a person for having those needs or those struggles, but there just wasn't a venue of getting real acknowledgement and help for any of that. So that kind of silent bravado and silent struggle
You know, it became very real to me that like, oh, that leads to death, right? I mean, it doesn't all the time lead to death, but it leads to death way more often than is even remotely acceptable.
I mean, I think as we've discussed, sometimes it can lead to death immediately, like in these cases. And sometimes it can lead to a functional death, which is you're still technically alive, you know, you still respire, but you're effectively dead. And in many ways, that's probably the more endemic, more sinister, more destructive over the long term, given its sheer volume problem, right?
Oh, absolutely, I think. And the deaths that we see in front of us, like actually, okay, that person is not breathing anymore, are they're a viscerally moving hallmark of what is so pervasive in our society. And I do think that I didn't understand that then, that in many ways, the way our society is structured and the way our matrices of achievement are structured really beckons us to death in life.
to losing touch with the basics of our own value system and essentially to incessant striving and not incessant striving to achieve, although we may see it that way, but incessant striving to not pause and to not feel the vulnerability that I think is so pervasive now. I mean, even in the 20 years, you know, since we went to medical school, I mean, you think about how pervasive
Media is right. I mean how there's just marker after marker after marker after marker that says that you're not good enough You don't have enough you're too vulnerable. You know there could be terrorists at any time your kids could be killed We could I mean it's one stimulus after another that tells us not to stop and to really value ourselves by the things that we really value
We get through med school and true to your word, you get a psychiatry residency spot. You decide to stay at Stanford in part because your wife was still your soon to be wife. You guys weren't married yet, but your girlfriend was a couple of years behind us in med school.
And you end up spending half your time at Stanford and then your wife matches at Harvard, so you go and finish your residency at Harvard. So whenever I'm telling patients about you, and I'm probably bastardizing all of my knowledge, which is so limited in this field, but I say, you know, one of the things about Paul that's so unique is.
He did half of his training at Stanford, which is probably one of the foremost institutions when it comes to understanding the neurobiology and the pharmacology and the pharmacology of psychiatry, and then does the other half at Harvard, which is sort of a more old school, but a place that specializes so much in the psychotherapy.
Is that an act? Am I making that up when I say that? Because I've just decided to take the liberty and say that about you. It sounds good, so please keep saying it. No, no. Actually, I think that there is truth to that. And there's even more truth to that. The longer I get from it and the more I reflect on it, I think that
You know, I'm not a very positive or hopeful person about the state of the field that I'm in, which I think does not broadly enough train people in brain biology, not just in the use of medicines, but in what those medicines actually do, and on a very real level. What are those medicines doing?
as interventions in the brain, in the many many systems of the brain, in the cascade of effects that occur in the brain, and we don't think about structural neurobiology, we don't think about neurochemistry in general. So there's that part of the field that often gets ignored, and then the other side is the psychology.
There has been a debate of should psychiatrists still be trained in psychotherapy? I see this come up and I just think that it's fucked up by putting it crazy to consider having people that are that are schlepping medicines to other people that aren't thinking about what it's like to really try and understand someone and what are the paradigms of understanding other humans, right?
the kind of things that are valid and have a scientific basis for them, but that are not hardcore brain biology. And I was very, very fortunate to learn so much neurobiology at Stanford and to have that integrated into my training. But when I got to Harvard, I was struck by
that several very prominent influential people there who were influential over whether I graduated, were really shocked at how much brain biology I knew, and really shocked at how much psychology I didn't know. And even though I had sought out some of this on my own, being in a place that was steeped in an older analytic tradition,
really helped me kind of embrace this belief that understanding psychology and certainly from the perspective of what's psychodynamic, right? The things that influence and motivate us that are in our unconscious. You know, the gigantic part of the iceberg that's underneath the water, but that is most deterministic of our behaviors and our choices and our feelings.
and being able to integrate that with the brain biology upon which it rests, I think it's the way to at least try and have the most broad set of abilities to try and help people. And in some ways it was very fortuitous for me to split my time between those two places and to find a couple very, very good people who took it upon themselves to try and teach me in a short period of time what maybe I should have learned over a longer period of time.
When those of us who are not trained in this discipline think back to our Psych 101 class or something as undergrads in college, you get introduced to all of the luminaries in the field. And one of the things I still remember was sort of the id, ego, super ego stuff.
How much of that stuff is still relevant today? I mean, even sometimes when you and I talk, we still, I think when we talk about personal things, this idea of ego still comes up. I mean, you and I both completely separate to all of this discussion, because we won't go down this path, it just takes too long, but we share an enormous interest in psychedelics and the promise that they hold for people. And of course, one of the hallmarks of this is dissolution of ego.
So when you think about what someone like me or someone who's listening to this, who doesn't have the training, thinks at a very crude level of the id, ego, super ego, how much does that still apply to how you think about these problems? I think it applies tremendously on a foundational level.
And the problems we often run into are often about semantics and even among like experienced psychiatrists, the definition of words and terms can obscure any understanding. So for example, in the Freudian concept of the ego, it's much more the whole self. It's the part of self that one can bring in a conscious way to bear on the questions and issues at hand.
the part of self that can mediate between the different poles, right? So the id may be about gratification, the super ego may be about what you should or shouldn't do. But ideally, it's the ego, the whole self that pulls that together. And that's a very different use of the term ego than how it often is used these days, where ego is a sense of self that essentially indicates a defense mechanism. And the idea of dissolution of the ego
Through the use of psychedelics is not dissolution of the classic psychodynamic or Freudian ego, which is like the whole self at its most poised and comprehensively aware and empowered. It's more the dissolution of ego as defense.
that we build up over time, I think a shocking number of defense mechanisms that serve us well at the time, but that ultimately are an unhealthy part of the foundation that then gets built upon.
So, for example, a sense of insecurity and childhood and I'm not good enough and I need to achieve more and I need to please people. You know, we build so much around that that defines us in a certain way, for example, right? That tells us that we must be perfect and we beat up on ourselves over less than perfect because that's how we're going to make ourselves perfect, right?
And then you can think of all the things that build on top of that, which could be maladaptive friendships, maladaptive romantic relationships, maladaptive career choices. There's so much that we can build on top of that. And in a very strong sense, it's almost as if the true us, the Freudian ego,
is surrounded by 90 story high walls that are built to protect us, but actually protect us from real connection with self and others and real understanding. And some of what the psychedelics, it seems through the phenomenology, the people's experiences, the research. When you put all of that together and you look at it with the brain imaging and the knowledge we have about brain biology is
is in an amazing way they can take down those defenses, which if not done in a therapeutic and a controlled setting obviously can be dangerous, but in the right setting opens one up to an experience of self and an experience of the truth of self that is no longer walled off by all of these unhealthy defenses.
So, it's a long answer to the question, but yes, what's going on in our unconscious? What's going on deep in our brain? The things that we're not consciously aware of are so deeply impactful. So Freud certainly didn't get everything right, but this concept of the unconscious pulls on us and the ability to integrate those things in a healthy ego that can actually decide and choose
I think is as relevant or more so than ever when there's so many pulls away from authenticity of the self. And then the hope of psychotherapy, just shared human experience and psychedelics is to be able to take those defenses down so we can have an experience of self that reflects who we truly are, which the vast majority of the time involves acknowledgement of
the things that we're ashamed of, the vulnerabilities, the things that we've ensured ourselves against, which are often the very things that keep us away from happiness.
You know, as you know, I'm writing a book now and it's not a particularly easy thing to do. I think it's probably hard even for someone who's a natural writer, but certainly for someone like me, it's very difficult. And I'm toying with a chapter that I've been really, really flailing with for the past three weeks. It may not end up in the book because I just don't know how to write it.
but it's a chapter that centers around the experience i had in kentucky which might seem like an obscure thing to write about in a book about longevity but of course, as i've become very clear on lately i don't think all of this obsession with longevity and living longer and living better means a lick if you're miserable and so much of our misery is self-imposed,
And I think, obviously, you are the reason I went there. I would never have done what was required to go through that experience were it not for you insisting on it. And frankly, even had you insisted on it at a different time without the confluence of events that led to it, I probably could never have done that because the vulnerability that's required to do and to go there and you even put me in touch with another patient who you had sent, who had gone. Again, the thing that amazed me about that was
How long I had lived my life never even considering the idea that. There can be a child that gets wounded that wounded child develops in an adoptive child and sometimes that adopted child is the one that shows up in the adult body and not as opposed to a functional adult.
Yes, yes. And I guess I just sort of feel like I'm Neo in the Matrix and after I've gone through this whole experience, I see my life in a totally different way and I realize, oh my God, like all of that achievement, all of that perfectionism, all of those things I was chasing, it's basically a kid trying to protect you.
And I've certainly not held out any hope that it's going to be ever fully resolved. I mean, I'm not. I don't know. Maybe I'm just too pessimistic. It's going to get better. I'm absolutely confident because it has gotten better, but it just strikes me as so hardwired that it kind of makes me wonder, like, is this something that's getting worse? Or is this something that has always existed in our civilizations and our societies?
and only now because so many of our other needs are being met. None of us, if you're listening to this podcast, you're probably not worried about where your next meal is gonna come from. You're probably not worried about a plague. You're probably not worried about, hopefully you're not worried about a civil war or something like that.
So, is it just that our basic needs, you know, of Maslow's hierarchy of needs, they've been mad. And so now we have the quote unquote luxury of worrying about self-actualization and what does happiness mean and what does it mean to be fulfilled and content that we're now realizing this? Or do you think there are things that are actually making it worse today? And there are more wounded kids out there and more adults that are effectively nothing more than adoptive kids.
It's such a fascinating question. And I mean, of course, I don't know the answer, but I do suspect that we are making it worse for ourselves in ways that we haven't intended. So of course, look, I'm all for opportunity. Meaning like we are numbing ours, we have more net agents to numb and soothe ourselves.
We've made more opportunity for ourselves in certain ways, right? And that opportunity is a wonderful thing in many ways. But every good thing has its potential for a downside and something that can work against or even negate the good thing. So for example, as far as I know, for generations, the people in my family live up in the hills of central Italy.
And as far as I can tell most of them are shepherds, right? And we could look at that and say, look, there's a limitation to what they could achieve and how fortunate am I that people sailed across the Atlantic and now I go to college and I have a business career and then I go back to school and I take undergraduate classes and I
I applied to medical school after all of that, and I get in, and you could list forever the additional opportunities that I have that people didn't have before. And that's wonderful, and I certainly would not argue against opportunity, right? But it also brings greater opportunity to run away from the things that plague us. So for example, you and I, and probably many, many, if not most of the people listening to this podcast, are driven to be powerful.
So, okay, some of the motivation for what I do or what you do is intellectual curiosity, the desire to help others, the desire to learn about self, right? But a significant aspect of the strength of the fuel in the tank, right, is running from something, right? It's running from vulnerability. Because there's more opportunity, there are higher expectations. And I think there are high expectations for both of us, not that I am arguing against
You know, the fact that our family is instilled in us conscientiousness and ambition. But I think we internalize that as must be perfect, must achieve more. Like when is, when is enough, enough? And it becomes very, very unclear and it becomes very easy to run from things.
You know, it's that that I think that the modern world doesn't actually help us define what we are striving for. So more striving, more power, whatever that means, right? It could mean money, it could mean prestige and titles, influence, whatever it means, like more of that by definition becomes better.
And we live in a world that constantly reminds us of our vulnerability. So there's never a time. I mean, my guess is having spent time in places where people are shepherds, right? And people do have these simpler lives. And sure, they don't have the opportunities we have. But there are ways that I often can see them at the end of the day.
feel a sense that the day is over and that what's the day's Exigencies are over the days ambitions are over right there like things are okay, and it's time to rest and they'll be tomorrow and I think most of us don't have that feeling you know most of my life when I fall asleep I'm exhausted and I have a sense that well now I need to sleep for a little bit so that I can get up and strive more and I don't think there's any way if we're honest with ourselves that we can frame that as oh that's a drive to something
No, that's a drive away from something, right? And it's running away from ourselves, and it's running away from our problems, and we don't even know what those problems are. And the fact that, as you know, I have a pretty diverse practice, right? That really, I think, spans the spectrum of psychiatric and neuropsychiatric things.
And I absolutely believe, and I've come to believe more and more and more and more as time goes on, that 80% of what I treat is trauma. 80% of what ails me, 80% of what ails you, 80% of what ails the world around us is all trauma.
There's another 20% that might be a head injury, schizophrenia, the complications of physical injuries, biological determinants of addiction. But none of those things, even those things that seem and are very biologically determined, are free of the impact of trauma. And the rest of it, I think, is purely trauma.
Its manifestation is anxiety, depression, panic attacks, choices to abuse substances, choices to do things that are unhealthy, whether it's overeating or it's cutting or it's gambling or whatever it is that we're doing. So much of that is driven by trauma.
And I think that, you know, yes, it's an opinion, right? It's not something I can prove that you can prove like a, you know, like a math problem, right? But I think if you really look at it and you look at what's going on at the root of what ails people, I think it becomes self-evident that I think there actually is a way of proving that, which is just
look at what's really going on in people. Instead of categorizing them, you know, the DSM-5, that's a half a city block long, that just looks to like, look, if we flip through it, I don't know how many diagnoses you and I would have between us, right? Because it's designed to capture everybody multiple times over, but categorizing what else somebody and putting a number on it
is not understanding them. That is not synonymous with understanding them. This is the tragedy of your profession, right? Is that the direction it's going in? It's designed to categorize. If you categorize something, you can put a number on it, and then you can get 20 bucks for insurance, and you haven't actually understood people. I think that both the practitioners in my field and the people who come to care deserve better than what the field gives them,
And we've stepped away from really trying to understand people. And I'll give you an anecdote. I was very, very fortunate when I was interviewed for Stanford. I was interviewed by Peter Rosenbaum, who was an emeritus professor of psychiatry. This was in medical school or for residency? No, for medical school. Yeah. And we got along really, really well. And he's a wonderful person.
Later on, when I decided to become a psychiatrist, I told him. I got his email out of the archives, and he sent me some redacted histories of patients. He wanted me to understand that, yes, there have been so many biological advances. There's space age and neuroimaging.
There's an understanding of brain biology that was unimaginable 30, 40 years ago. But if you look at what they were writing about people, they really evokes a human being. Whereas very often now, when I look at reports of people, I can't tell anything.
It's just it's an inventory of signs and symptoms that you could conclude anything from and then a number gets put on top of it. And yes, I mean, I'm being critical of the field as I'm saying this, but in many ways it's a societal criticism. It's a criticism of a society that dumps things down and that doesn't respond to the individual whether it's the
incessant phone trees that prevent us from ever solving any problems, right? No matter what it is, whether it's my banker, it's the phone company. I mean, when do you actually connect, right? And I think it's that isolation that is a societal malady and it affects psychiatry, which is a very bad thing because psychiatry is trying to help us have better mental health and we're kind of disarming its ability to do that, I think.
And then it pervades our society in a way that leads to isolation and desperation. And if you look at suicide rates and just levels of general misery, I mean, I don't want to glorify the past, including the recent past, but it's pretty hard to look at that and to think that there's not something here that's getting worse.
Yeah, well, I mean, touching on that, there was an article in the Wall Street Journal recently after the sort of very close to back-to-back suicides of Kate Spade and Anthony Bourdain. And it showed some stats from the CDC. So these are obviously US-based statistics.
When you looked at men and women between the ages of 40 and 60, across the board, there was about a 30% increase in the rate of suicide. I don't want to be misquoted on this. It was either a decade or two decades, but it was a relatively recent period of time.
And my approach to longevity is very, it's very cludgy, right? I mean, I'm kind of a hack if you really stop to think about it. I don't have like some single magic pill that I think can make you live longer. Instead, it's like a whole bunch of reverse engineered problems. And one of them is, you figure out what it is that's gonna kill you and start to back out of that. And so I spend a lot of time pouring over actuarial tables and looking over mortality trends and trying to understand how they're shifting where are we, quote unquote, winning and where are we losing?
It seems to me that even though most of my energy focuses on three things, atherosclerotic disease, cancer and neurodegenerative disease, the only disease that shows up in every single decade as a top 10 cause of death outside of the first decade, so birth to nine, is suicide. Accidents do as well.
I think the suicide thing, but the nature of accidents, by the way, changes so much from beginning to end that it's a very different. In other words, the accidents that kill 30 year olds and 40 year olds are quite different from the accidents that kill 80 year olds and 90 year olds.
And sorry to interrupt, but how many of those accidents, especially ones that are killing younger people, are what we might call paras suicidal, right? It's people being reckless and getting killed because their mental state is such that they're not invested in staying alive. Not only that, so that's a great point. The other point is when you look at the top three causes of accidental death, it is automotive accident falling an accidental ingestion, which of course begs the question, how many accidental ingestions are not accidental?
When I was in college, a friend that I grew up with, his dad shot himself in the head. I remember the Sunday afternoon that it happened. Literally, they all went out to church like a normal day, went out for lunch after, and then when they got back home, his dad went out to the shed and shot himself in the head.
Probably one of the saddest lessons I ever learned was maybe two months later during finals. My mom said, so-and-so, my friend, is not doing well. He's really down in the dumps. You ought to come home and see him this weekend.
I still to this day just cannot, I can't believe what I'm admitting and acknowledging now it's so embarrassing and painful to say this. But I said, Mom, look, I'm in the middle of finals here. You know, I got to graduate first in my class, right? I have to be the best engineer that ever lived. I'll be done in two weeks. I'll see him then. A week later, he was dead.
Oh my gosh, I'm so sorry. Now, we don't know, you know, I don't know that he'll get counted as a quote unquote suicide because it was alcohol, barbit, you know, it was like a cocktail of drugs in his system and he just never woke up. And again, I only tell that story not because it's, you know, it's just such a sad, it's a sad reminder to me to how to prioritize. It's that overnight change the way I prioritize things in life.
But it also begs the question, you know, his death might not be one that actually gets counted as a suicide, but I would call it a suicide. Absolutely. I mean, the deaths by suicide are in general the ones that are just very clearly suicide, right? Yeah. But if you... There's a note written that the gunpowder is on the hand as the gun points at the head, yeah. Right. But so many deaths that are not labeled as suicides actually are suicide.
And so many that aren't someone saying, I'm going to kill myself now, are the result of an approach to one's life that doesn't value it and wants it to end, what gets called paracenside. When you add those things together, those numbers, it just undoubtedly are strikingly higher.
than the shockingly high numbers that we're reading now. And I've always kept a mental note of if someone I know, you know, which includes, again, I don't make much of a distinction in people, my personal life, my patients, people I consult to, I mean, just humans, right, of what they died of on the death certificate versus what they really died of.
right and it might be auto accident accidental overdose fall right and I'm looking and I'm saying that person died of made-off that they're so ashamed of what happened to them when they were swindled and humiliated right that person died of rape that was never adequately addressed and the the sense of shame and the sense of misery that was imparted on them was never addressed that person died of childhood bullying right that was
so intense. They decided that they were this awful, reprehensible person in sixth grade and that never changed. I mean, every now and then, the actual cause of death matches what is, you know, my brain registers as the real cause of death, but very, very often there's a difference.
and the difference I account for by the role of trauma, the role of trauma that pushes people to either end their life or to move towards the end of their life, even if they're not overtly acknowledging that they're doing that.
which can be a clever way of not having to feel accountable, right? If the religion says, don't commit to it, say, well, it's ultimately, it was an accident or, well, I don't want to leave my kids. Ultimately, it's an accident. I mean, I'm not saying that in any negative way, but we don't help people to understand what's going on inside of them, right? And you're talking about how you run your practice and how you try and understand the routes to not just to longevity, but to healthy longevity.
And, you know, and I would argue, I mean, my take on that is that you actually have become the best engineer, because what you're doing is, as you said, you're reverse engineering to ways of living longer and being healthier. And with so many complex variables, I'm not so sure if it's possible to figure that out without reverse engineering.
And I view it as a marker of your, I truly mean this, your intense and incredible thoroughness that you look beyond the factors and the reasons for the factors and the reasons that underlie the factors and the reasons. And it's, you know, I think what leads you to have me here instead of someone who could talk more about oncology or cardiovascular pathology, right? The realization that what undergirds a tremendous amount
of the things that actually take someone's quality of life or take their life ultimately has a root in mental health, right? That people who are depressed are more likely to die of cardiovascular disease and more likely to die of accidents or more likely to become addicted, right? People who've been through terrible trauma are more likely for all of those things to happen.
the role of stress in its impact on the immune system and the growth of cancer cells, right? There's a level underneath the things to which we attribute morbidity and mortality that strongly influence morbidity and mortality. And I believe that's true. I mean, I think that 80% of what I treat is trauma, but I actually think, I don't know what the numbers are, but I think more than 50% of what everyone treats.
any doctor, more than 50% of what walks through that door is ultimately resting in misery inside of that person that I would attribute to trauma. And again, it's not my way of saying, oh, we're all suffering and in some way that it just kind of denigrates, you know, when really awful things happen to people. I mean, the problem is we don't take stock of really awful things that happen to people like most of the time.
And even when those things are something so overt as an assault, a terrible loss, we can ignore even those things, let alone the impact of loss of a parent as a child, loss of a friend who moves away, loss of a pet. These are things sometimes that
that you ask somebody what their inner life is like twenty, twenty-five years later, and that thing may go through their head a thousand times. And it may be that the loss of the pet is symbolic of they will have no stability, no peace, no freedom. So then it becomes the internal symbol.
of their sense of hopelessness in life or their sense of infinite striving with no hope of getting where they want to go. So I don't mean to say that in some, I don't know, trite way, but I mean to say it in a way that I do think, if you sit with individual people, you see the depth of that and you see the pervasiveness of
When you recommended that I needed to go to Kentucky, needed to go to this place, the bridge to recovery, which we'll be sure to link to in the show notes here because I really think if anybody takes anything away from this and they even have a suspicion that some of their actions, some of their pain could be sort of driven by trauma that had occurred in life. I want to make sure that people at least pick up the phone, give them a call and at least commit the time to doing an intake interview with them.
I mean, I was so incredibly resistant to this idea, right? It was this idea that how could there really be anything wrong with me? Look at how hard I work. Look at how quote unquote successful I am. And by that I just meant like, I'm not an alcoholic. I don't have a drug problem. I'm not a gambler. Like I don't have any of these overt signs of pathology. Yeah, I've got these other things that are kind of pathologic, but I can mostly keep them in check.
But I kind of remember when I did my intake call with them how pissed off I got. And that, to me, there was two things, right? So the first is I'm talking to this poor woman whose job it is to just do a basic screening call. But she's asking me a lot of questions nobody's ever asked me. And questions I don't want to answer. And at one point she asked me a question. I won't tell you what the question was. But my answer was, fuck you.
Like that was just my answer right like and When I later told that story once I finally got there everybody thought that was so funny because they're like wow She asked you a question about X and she found out you have X and a bad temper It's like it's really great anger management and this other thing check But that was also kind of the reason why that was certainly one of the things that made me think because as you recall You know you wanted me to go and I agreed to go and then I backed out and you know it's just like
This had been something that had been on the table for years, and I just refused to acknowledge this needed to be done. And I think part of it was the semantics, right? It's like, what does trauma mean? We get so far in our lives, our skin gets so thick that I think people get into different patterns. And for me, I know the pattern was minimization. You know, I didn't forget any of the stuff that got me there.
I just didn't think it mattered. You know, when they talk about trauma at the bridge, they really refer to it in five roots. So the first root is abuse, which can be physical, emotional, sexual, spiritual. They talk about neglect, abandonment, enmeshment, and the witnessing of tragic events. And so I think it would be impossible to think that somebody listening to this hasn't experienced at least some of one of those branches, and many of us more than one.
For me, the single most powerful way to let my guard down was, because we're now, what, three or four days into the most intense experience of my life, which is 13 hours a day of group therapy. And I had still sort of, I mean, I was there, so I'd shown up, but I wasn't happy. But I'd refused to sort of even have a discussion about any of this stuff. I was happy to listen to other people, but I wasn't gonna get into it.
And one of the counselors, and I had these two amazing counselors, Jeff and Julie, I can't remember if it was Jeff or Julie, but one of them said something to the effect of, you know, if such and such, because we were talking about an event in my life, if such and such occurred to your son, Reese, because Reese is for about the age that, you know, I was, would you think that was okay?
It's a very different question. It's one thing when it's like, look, that happened. I'm over it. Come on. I could even rationalize it. Look, these things have made me more resilient. This has given me a chip on my shoulder. This has given me an edge. But when they turn it into, you have a kid. And it's so interesting because just last week I was having dinner with a friend in Malibu.
And he opened up to me about something incredibly personal and private that I'd never known, which was that his wife had had a really difficult year. She'd relapsed in her smoking. A whole bunch of other stuff had completely fallen off the rails in their lives, but in particular in her life. We get through the whole dinner and he tells me everything about the story and it's just a heartbreaking story.
And then he alludes to a fact that was clearly the trigger, which was his wife had been abused very badly by her stepfather, had been sexually abused, nonstop, started when she was seven years old.
earlier this year, their daughter turned seven. And it completely triggered this because, and again, if I'd heard that before, I would have been like, come on, that sounds like sort of psychobabble nonsense. How is it that seeing your daughter at the same age that you were at when something happened could do that? I mean, do you see this often? Oh, sure.
Yeah, absolutely. And to kind of lead up to addressing that, I want to comment on a couple of things, right? One, you said that the woman who was asking the questions, okay, she learned, okay, there's this issue, and then she learns about anger, right? I would frame that a little differently. I would say that.
that there's a very skilled clinician that is doing the same thing over the telephone that we might do physically examining a patient, right? And he touched, does it hurt here? Does it hurt there? I mean, if you get where it hurts and we're not, even if we're very gentle about it, right?
at times the person has a reaction, right? And then you learn like, oh, you hurt there, right? And that's why you reacted that way. And I think that's what she learned. Jesus is it heard here? Is it heard here? And then she'll know, shit, it really hurts there. And, you know, it tells us something, right?
And what it tells a good mental health clinician is where there's shame and fear. And shame is extremely powerful. And technically, it's an aroused affect. I mean, the word aroused, it's not
purely a sexual word. I mean, it often gets used in that way because the idea is something can turn a person on that you didn't choose to have turn you on, right? But the idea of aroused affect is something that's created in you without your volition. Someone shoves you, you get angry, right? Someone shows you really hard, you might get afraid, right?
There are things that make a certain, what gets called affect, but colloquially a feeling inside of us that we don't have a choice over. And there's an incredible automaticity to that. And that's what you're talking about with
Okay, like, what is this trauma thing and what is it doing, right? It's not necessarily what happens. It's what does it make you feel? And my guess is, and I don't know, I don't know the person you're talking about, but probably that person is carrying some sense of shame over what happened to her.
Because, you know, at the age of seven, you know, that there's not the cognitive capacity of deciding, look, what's going on? Happening to me is wrong. You know, the child needs to make sense of it, right? And often how the child makes sense of it is to decide somehow that it makes sense or what's happening to them is deserved or it's their fault, right? Or it's the way it should be, right? And that evolves into a sense of shame that the problem here is me.
someone's hurting me in some way, whatever's happening to me, doesn't feel good. And it's my fault. And then it creates a sense of shame that does not give a damn about the clock or the calendar or levels of achievement. You have a trillion dollars and 15 PhDs, right? It does not make a difference unless that shame is directly addressed. So that's really the answer, right? Is what has happened to a person and what is it triggering inside of them? The same way there's
Pretty good literature that talks about, you know, someone is shocked, right? How much does it hurt? And like, clearly it hurts more if there's no damn reason to have been shocked, right? Like if you try to save somebody and, you know, when you get shot, then people tend to feel less pain because there's a sense that it makes sense in some way, that this bad thing has happened, but something good has come of it, or I was trying to do something good, right? It doesn't seem senseless and sadistic.
and that sense of absurdity, the sense of evoked shame or aroused affect of shame, the sense of an aroused affect of fear, the sense of absurdity and meaninglessness is what then creates the trauma that stays with someone and kind of like
It's not even like a ghost shadowing, you know, it's like, you know, just imagine someone who like can't stand you that just shadows you all the time and says awful things. And that's essentially what this kind of thing evolves into. And it's that that, you know, that raises that triggering, that if there's still a sense of shame,
And now the daughter is seven years old. What does that make the person feel like? The person identifies with the daughter. They still identify as the hurt child. But now they're supposed to take care of a child who's vulnerable because that child has reached the age at which they were hurt. I mean, it's very, very triggering for reasons that make damn good sense.
So you've seen this where people's trigger is a child that reaches an age at which some traumatic event occurred. Yes, it's very common because that is a trigger that say, OK, it's my job to make sure that does not happen to them.
But I am still in the throes of it. Right. So then what I am the traumatized seven year old child who is supposed to protect the seven year old child, that's terrifying. It's terrifying. And then the part of the brain that is terrified says, look, this absolutely could happen to your child. And you can't protect them. And then, you know, the brain again, the brain doesn't care about the clock and the calendar. So that trauma is very, very, very real to the person.
and it's very immediate it doesn't matter if it was two days ago or if it was thirty years ago it's just as immediate and and we also lose sight of that and many times i hear people so i couldn't still be bothering me it was what two months ago two years ago fifty years ago and and the answer to that is it does not matter one bit how long ago it was
if it instilled terror, shame, a sense of responsibility for something that wasn't the person's responsibility, then my guess is we could probably live to be a thousand years old and that would still be with us. And again, very germane to your practice is that's one of the things that often prevents us from living longer.
It's that kind of internal stress that leads not only to suicide and para-suicide, but also to the kind of stress that contributes to cardiovascular disease, to cancer, to autoimmune problems, to all the things that ultimately, if you look at the population as a whole, that chips away at our healthy lifespan and at our lifespan.
I still remember to this day the very, very first patient we ever collaborated on, which of course was such an interesting experience for me that it's what basically led to you and I being so close at the hip in terms of like how many patients we overlap with. But I obviously won't use her name, but the woman in San Diego that I was taking care of, very interesting case.
I think most of my patients are incredibly nice people, but she would certainly be on the short list of like the nicest and just a very, very special woman. Yeah. And there were a lot of things that didn't look metabolically right. Frankly, her chief complaint when she came to me was, you know, she just wanted to have more energy. She wanted to, to feel better. Her father had died prematurely of heart disease. She wanted to make sure that was not going to be her. And we got to it.
We changed her nutrition and we fixed her hypothyroidism and we tweaked a bunch of things and everything on paper looked right, but we couldn't eradicate certain things. There was still a degree of inflammation in her body. There was still a degree of insulin resistance. I probably hadn't seen a patient who could be so compliant with her nutritional plan as she was.
And the only one of her meds I couldn't really offer any input on was she was on an SSRI, I think. I don't remember which one. It was well-butrin if I can remember actually. And I think this had been prescribed by her family doctor like 10 years early or something like that. But I remember one day thinking about what she talked about when her dad died when she was in medical school. She was a physician.
And it cleared me on this particular day, which was a year after the first time I'd heard this story, that I didn't know to use the word trauma, but that was clearly a traumatizing event in her life. And my first thought was actually, I thought of these zucker rats, which I thought of these experiments that occurred, because what I couldn't understand was, why in the world is this woman who's doing everything right, seemingly have a metabolic rate of a slug?
It was like she's doing everything by the book and the only way that we could infer what's going on with her is that her metabolic rate has shut down because she's no longer hypothyroid. All those other things have been fixed. I thought about these zucker rats where they sustain certain lesions into parts of the hypothalamus and they can alter the metabolic rate.
And so i floated the idea by you and you said look anything is plausible and to make a long story short i introduced the patient to you she came up she saw you. And over the course of the next six months without making any change in the thyroid meds in the nutrition exercise.
She probably lost 30 pounds. And she looked like a different person. In fact, I remember when I got her Christmas card with her and her family. At first, I thought, I don't know who this is. Why am I getting a Christmas card from a random person?
And I mean, what do you remember about that case? Maybe not even the specifics, but just like, were you as surprised by that as I was? You know, I think the fact that I wasn't is just indicative of it's not indicative of like some genius that I figured things out that other people haven't. It's just indicative of things that I have witnessed.
that utterly shocked me at the time, that lead to what I would describe as more than a healthy respect, but an utter reverence for the impact of what the brain can do to the body. And a couple of examples are paralysis of a limb. I've seen people, seen cases in my training, and subsequently taken care of people
who do something that they find reprehensible or almost do something that could have been disastrous, and then the limb that they did it with is paralyzed. And now it's like it's 10 years later, and the limb hasn't moved in 10 years.
The nerves haven't been severed, but they may as well have been those contractures and everything else. I mean, when you see that the brain can shut off vision, the brain can shut off movement to a limb, these are really shocking things. And I think that we as a society, we just don't appreciate how much impact over all aspects of our functioning, some of the things that torment us inside can have.
So there was something tormenting this lovely woman that was like shutting her metabolism off. And in many ways I get it's a shocking thing and it would have knocked me off my feet if I hadn't been like seen paralyzed limbs before and you know things that really kind of told me things that to be honest
really made me angry. And I thought, like, how is it that I consider myself to be a curious person? I mean, even before psychiatric training, right? And I'm a well-read person. I'm a well-traveled person. I'm interested in other people. I took a broad curriculum in college. Like, how is it that
I didn't understand these things of what our brain and what does that mean? It means what our brain in the context of trauma, which is about evoked shame, fear. Think about things we're talking about in the patients where we've had these kind of experiences, right? And even in ourselves, think about the impact of shame and fear and what it does to us. And people don't tell us that.
So then a person feels ashamed, right, that they're eating less and they can't lose weight. They feel ashamed that they're sleeping, but they're not well rested. They feel ashamed that they want to be patient with their kids and they can't be as patient as they want. I mean, I could go on and list thousands and thousands of things.
What we often don't, again, don't appreciate is where's all that coming from? And is anyone ever asked about it? I'll give you a very quick aside that I saw a person in my practice several years, maybe five years ago or so, very, very intelligent person, very capable, academically accomplished, who was working many, many, many levels underneath where
uh, he could would have been operating, you know, $10 an hour job and somebody, you know, who should be running a company that dramatic. And, you know, I was, I don't know how many people had seen and talked to this person before, right? And I asked him a question and, you know, we had been talking. So it's not like it came out of the blue, but, but I asked him, you know,
How many times a day do you say something to yourself inside? That's some version of like, I suck. And this response was also, I'm a piece of shit. And his answer was like, he stopped, it was hundreds, hundreds of times.
all the way to the job, all the way back in the shower before he goes, when he's back at home with his kids, nonstop. You know, that was all trauma-based, and it was based upon belittling, bullying, all things that had happened. I mean, you could take a trauma history from this person, and no, like no one's ever shot him. No one's ever sexually assaulted him like it was, oh, there's no trauma. Oh no, there was gigantic trauma.
And if you're saying something to yourself over and over and over again, that is profoundly negative and that makes you feel vulnerable, ashamed, inadequate, how are you supposed to be at your best? How does it affect your brain? How does it affect your endocrine system? How does it affect your immune system? How does it affect your vasculature? The answer is dramatically. And then you look at this person who now was aware of substandard role performance and now he feels worse about himself.
And by going after that, we're actually able to change everything. I mean, that the person's life is dramatically different. If you look at what he's doing for a living night, you're like, OK, that's something that seems more commensurate. And in this person, it doesn't represent the endless striving of you who could never achieve enough. In this person, it represents something that makes him feel whole, that this wasn't his ability to be something he could feel proud of, to support his family in a way he could feel proud of. It wasn't taken away from him.
But if you look at what was the etiology of that problem, it absolutely wasn't single digit ages. And it doesn't matter that this was like three or more decades along, right? It was with him hundreds of times a day. And that's why these things don't surprise me. And, you know, I've had an increased awareness over time of my own inner voice.
that I may as well as somebody behind me all the time. I've been trying to alter this in some ways with your help and a couple of other people around us. It's gotten better in the realization that I carry around with me a voice that tells me how shitty I am for everything that's not utterly perfect for the moment I wake up to the moment I go to sleep.
has created a lot of misery in my life and has created unhealthy situations. And, you know, at times, real risk to life and limb for me. So, you know, I'm a huge believer that the reality and the truth that we're living has the reality and what we view as truth, that we're living in is often not apparent to anyone around us and nor is it apparent to ourselves. And if we make that apparent, then we can make some decisions about it.
which is why that woman was able to lose weight is because we started talking about like what was actually going on inside of her and you know in a certain person if you are intensely ashamed and feel inadequate from the moment you wake up to the moment you fall asleep you probably 20 calories a day and you're going to gain weight.
Yeah, that's the part that just blows my mind in her case. The other thing with this stuff that I think it's worth people who are listening, understanding, and it's so important. I certainly didn't understand it until the past year. I think I wasn't so naive to know that I wasn't so maybe naive is the wrong word. I wasn't so ignorant to think that, look, bad things happen. I got it.
But my sort of blind or based mentality was, I can prevent that exact set of things from happening to the next generation, to my kids. And of course, the irony of it is you learn that trauma almost always comes out in some orthogonal way. And so it's not necessarily that the child of the alcoholic becomes the alcoholic.
In the case of the woman that I was just talking about earlier who when she saw her daughter turn seven triggered all these flashbacks of the sexual abuse. I don't think that I think the probability that that mother is going to go ahead and like sexually abuse her daughter because she was sexually abused by her stepfather. I think the probability that is like close to zero. That is not how the shame will be transferred to the next generation. It will not be through the same root cause. It will come out in something different.
And to me, that's the part of this thing that is such an epidemic. You know, Terrence Reel, who we've talked about a lot in his book, which I've talked about on other podcasts, one of the most important books I've ever read. I don't want to talk about it. He talks about this, the number of generations it takes for shame to sort of work itself out.
And it's like, you know, this happened to the grandfather, this happened to the mother, this happened to the child. And this idea of shame, transference through trauma is, I don't know, I guess, like I said, even though I don't do this for a living, it occupies more and more of my time, because I spend more and more of my time thinking about it.
With the patients that I'm lucky enough to get this close to and truthfully, there are some of my patients I just don't get close enough to to understand this part of their lives. But I want to because I realize so much of what we do without knowing this becomes quite futile.
Well, absolutely. I mean, if the only thing we were guarding against was the manifestation of something that we recognize, things would be different. I mean, I think the number of generations to get rid of shame without intervention, you know, is either infinite or there's just some... You know, it's practically infinite.
Right, because why would something like that change unless it's understood? Now, people at times can intuitively understand. I mean, there are things that can intervene, but otherwise, you're absolutely right. I mean, it finds a way out, right? So the person who was sheltered and over controlled as a child, and that led to, say, big problems of rebellion and then something traumatic happens,
Maybe if they don't understand it they may overcompensate with the sort of freedom and what seemed like opportunity for their own kids But why it actually you know puts them inadvertently in danger Just as the person who was neglected and was then left in situation of danger May over control their kids and then the kids were bail and the same thing happens I mean if we don't understand it There's a very good chance that it will find a way to get us and you know sometimes that's something dramatic and
And, you know, I see these cases, like, oh my gosh, like this person did the opposite thing. Their parent did look the same thing. Happens, right? But a lot of times, you know, I think most human suffering and most bad outcomes, you know, happen with a fizzle, not a bang. And I think that's part of the really the biggest sadness of it. It's the things that we don't know or the person who just languishes, who doesn't have a strong sense of self and is burdened with regret. And that's the story.
I mean, there's so much about this that because we don't talk about it, we don't educate ourselves about it, we just let be perpetuated. And in many ways, like, I'm not trying to say, oh, this is all easy to address, right? But some of this, I think, is low-hanging fruit of, look, why are we not talking about these things, right? Why is it that we enter medical school and you have all these, like,
Overly powerful guys and you know, we don't think about like what are we all defending against? Like why do we have to be so powerful all the time? What are we guarding against? Why is it that we feel ashamed if we're not? Powerful right if we're not you mean if we're not perfect if we're not the best right? Why is it and and?
And I'm not saying, gee, let's have some soft wave going about life, and then people aren't driven to achieve things. But a lot of it is based on this lie that what doesn't kill us makes us stronger. OK, that is a lie. Sometimes something doesn't kill us and makes us stronger. We can get an infection. It doesn't kill us. We develop antibodies. It can happen on a biological level.
It can happen with a life tribulation, but my experience in my own life and in the people around me that I take care of or my friends, family, patients, like the humans in my life is that bad things that don't kill us off to make us weaker.
They hurt us. And if we don't acknowledge that, what has this thing done to me? Then we put it onto the surface and we soldier forward. And for a lot of people, what does that mean? I mean, it does mean languishing. And oftentimes for people who maybe are blessed with more drive and perseverance, sure it means we drive ourselves to achievement, but amidst all that achievement, we remain miserable.
because the hurt part of us is still what we're living in every moment. Most of the time we're living in that hurt person, but that hurt person is festooned in a way that doesn't look like that. And if you think about very powerful things in culture, the Wizard of Oz, such a cultural touchstone across generations, even the Emperor's new clothes, we're infatuated with
things looking some way, but being another way, things looking strong and powerful, but being weak and vulnerable. And part of our infatuation with that is it can take the fear out of some of the things that scare us. But I think an even bigger part of that is that we often identify with that.
We identify with festooning ourselves, look how great I am. I'm not festooning in anything. There's a pathetic nakedness to some of it. But we sort of posture that way. And we posture that way in order to show ourselves up. And if I see a commonality between how you and I practice medicine and how the vast majority of I think good doctors practice medicine, it's not hiding vulnerability.
I do not feel in any way, shape, or form healthier than the vast majority of my patients. I mean, some people, yes, I've had a bad day of injury. I have schizophrenia. Okay. I don't feel any better necessarily healthier to them a lot of the time, but there's an identified problem that we want to address and treat.
that can let the person feel a greater sense of wholeness. Okay, that's valid. But most of the people that I encounter are just struggling the same way that I am. And, you know, there really is no difference except that person may do something, maybe someday I need an architect to
financial manager, you know, lawyer, whatever it is that they're doing, but we're no different. It just happens to be like, okay, this thing I do brings them to come to me for help about this certain thing, but we're all people trying to make our way and survive in the world.
And often, some of the people who I feel are most put together are not the people that you might think. They're the people who, if you look at their achievements, you're not going to be wowed by it necessarily. But they're people who have a greater sense of wholeness. They're people who have maybe spent more time and effort on themselves. And this is not an anti-ambition agenda that I have here. But what I absolutely am saying is
that very, very high levels of achievement are a marker in my brain for suspicion that this person is defending against something. And, you know, that's the reason why I felt that. You should go to the bridge. It's the reason why trauma therapy is part of my psychotherapy. It's the reason why at some point I should go to the bridge too, right? I mean, this... You know what the nickname for that place is? You're the first person who told me I send a bunch of people there and no one tells me this and then you do. I do want to... It has two nicknames.
can't misery and the crying factor. It points out that making ourselves healthier often is difficult. It does involve misery. It involves tears and exposure of things we're ashamed of.
and you know all the places that i have sent people in you know this point almost two-decade career you know i think that they are the most effective or among the most effective of places and i think part of it is because they don't shy away from i remember something you said to me because you suggested look there are two or three places where i think you could go here's why i think the bridge is the best for you and one of the reasons was
I'm almost embarrassed to admit live to people, to so many people what I asked you, but I said, you know, Paul, when I looked at these other places, the bridge seems unique in that the socioeconomics of it look very different from where I've come from, meaning
I'm not going to be there with other people who have gone to medical school or gone to law school or whatever. Will I have enough in common with the other people there?" And you said, that's exactly why I think you should go there. And I didn't understand that. So I go there. And of course, the first rule is everybody has a roommate.
Well, I don't want to goddamn roommate. I'm 45 years old. I passed that course, right? I did that. I did summer camp already. I don't want to roommate. So I, you know, have my assistant call over and say, Hey, we'll pay extra, but he needs a solo room to which they sort of said, thanks for telling us how to do our job. That ain't the way it works. He gets a roommate.
All right. Again, everything that they did that I thought was pure torture turned out to be perfect. There was exactly, and it's exactly what you said. I had to be around people who I could relate to intellectually, who I couldn't relate to intellectually, who I had a similar education to, to whom I did not. But in the end, what I realized was
We are all the same. And that is such a banal, glib, idiotic statement, but it's fucking true. We are all the same. My roommate, I swear for the first three days, I thought, I don't have one thing in common with this guy. I loved him out of the gate. I mean, he was just an amazing guy.
But it's like, we don't have anything in common. And that's fine. I mean, it didn't make me like him any less. But two weeks later, I realized, oh, actually, we have more in common than I would have ever dreamed we have. The reason we look like we have nothing in common is perhaps some innate wiring, perhaps some stochastic events. But in the end, we took very different divergent paths. Mine led me to college. His did not. My weaknesses led me in a different area than his did.
One of the things that I found most powerful, and I'm bringing this back to a point you made earlier, was in addition to 13 hours of camp misery every day, seven days a week, you get to go to a 12-step meeting every single night. And you get to pick what it is. So they're not going to tell you which one you're going to, but you're either going to AA or Alonon or CODA or NA or SA or SLA. You're going. I think you got one night off a week. I think Sunday night you got spared the meeting.
And I remember thinking the first few times, like, I'm so tired. I'm just so emotionally exhausted that, you know, it's 7 p.m. or 8 p.m. All I want to do is go lay on my shitty bunk bed and sleep.
But they're like, nope, you got to go. And you're a guy, by the way, who could work? What? How many hours constantly as a surgical resident? Yeah, this was a different level of fatigue. So the fact that you're that exhausted speaks to like, what's going on, the magnitude of what's going on inside of you? I find that to be like, like fascinating and a great proof of concept.
Yeah. This in many ways hurt more than swimming the Catalina channel every day. Wow. Okay. That's something. Right. So, but what I realized when it was all said and done, because I, I ended up being quite surprised at how much I really got out of being in these 12 step meetings.
And I wasn't a participant. Every meeting I went to was an open meeting. I never once spoke. Never once. But I was so moved by the vulnerability of these people. Now, again, part of that might be an artifact of the fact that we were two hours outside of the nearest civilization. I mean, we're an hour outside of Bowling Green, Kentucky. Like, we were in a place that I wouldn't know how to find on a map if my life depended on it.
But I couldn't believe the vulnerability in these meetings. And I think in many ways that is an antidote to shame. It is the beginning of it. And fast forward five months, I'm back. I'm back into my life. And obviously much of my life has changed a result of this. But look, we still struggle. We're still always thinking about these things. And I remember my therapist in San Diego said something that I thought was so profound. She goes, you know, Peter, part of the problem with you is
You're always the smartest guy in the room now. She didn't she was sort of mocking me She wasn't like actually telling me have the smartest guy in there and she's like you basically are always the one on point You're the one talking you're the one giving the advice you're the one who everyone's looking to for the answer and the problem with that is like you never get the chance to listen and Not say a word and not have anybody even give a shit that you're in the room and
I was like, you know, that's the key. That's the thing I miss about the 12 step meeting was nobody gave a shit that I was in the room. And even if I was and I said, yeah, my name is Peter. It's like, great. Thanks for being here, Peter. You were no better or no worse than anybody else in this room. And so in many ways, I feel like, and again, I don't think it has to be the 12 step stuff. I know people are going to listen to this and say, oh, 12 steps a bunch of nonsense.
What works for you works for you, but the point is there is really something to be said for that type of vulnerability in a group where nothing else matters. It doesn't matter how much money you have. It doesn't matter how many degrees you have. It doesn't matter what you've done. I mean, none of those has been. And of course, the next place where that became the most riveting to me was on this prison visit that I went to, which we've talked about as well.
Again, just another great example of how in that moment, in a moment of redemption, all it matters is where you are in that moment. And I just find that. Again, as I'm sitting here and listening to all of the things you're saying, of course, my mind is immediately going to, okay, what can we do? What can we do? What can someone listening to this do? What can someone listening to this who's identifying with this saying?
You know what, like maybe that thing that happened to me when I was 10 or maybe this behavior that I have that's on the surface reasonable, but underneath the surface is maladaptive. Maybe that needs to be revisited. And again, if the answer is they need to seek therapy, fine, but what else can people do?
I think that it's so important to try and take stock of how are we trying to separate ourselves from other people. I mean, think about the things you're saying. It's very interesting and people listening to this who know you will know that this is true. And for the people who don't know you, please, I would ask take my word for this. I mean, you are
You know, the least entitled condescending human being, right? I mean, you do not feel superior to other people. I don't think I've seen one would of that in the two decades. I've known you. So why is it that you want a private room and that you want to be different? It's a reflex. And the reflex is, like, I've got to stand out in some way because that's what allows me not to feel superior, but to not feel ashamed. And that's often what is driving us.
It drives good things, right? I mean, your expertise and often being the focus in the room because you have, you know, things to say to offer is like, these are good things. But they're also driven by the need to separate ourselves. And, you know, it's not that both of those sides of the coin have to come together. But if we're not aware, they do come together. And then you're doing something by reflex that is the exact opposite of what you need. What you need is
to be part of the humanity around you, right? What you need is to relate to people. What you need is to feel that, my God, I'm a human who suffers from human things like these people around me, some of whom are nothing like me, some of whom may be like me, but none of that matters.
where all people and our suffering is shared. That takes away the unique stigma of the things that you are suffering from. But your reflex as mine has been, and as is the case in many people who are sort of driven to differentiate themselves, is to differentiate yourself so that you guarantee loneliness.
And, you know, that's what people I think really should try and be aware of is when are we differentiating ourselves from the world around us because we are trying to escape from something, but in doing so we isolate ourselves. And we don't get a chance to just be human. We don't get a chance to just be people. Like, you know, the people who are there at the bridge with you
had trauma and suffering and they needed to express emotions and they needed to cry and they needed to get angry and you did too. And I have too and so many people need that to heal but we work so hard to separate ourselves from that.
And that's what I think, you know, if there's one thing a person is going to be attuned to is how much are you separating yourself from the humanity around you? You know, groups of people when people have agendas or angry can feel threatening and intimidating. But there are many places that people gather in order to feel some sense of openness and shared humanity. And that's really what we're all seeking.
You know i know you know this but seven eight years ago and i had a clinic that myself and i practice partner built to be relatively sizable and we were doing a lot of individualized treatment and we were running groups and the groups were running around addiction. And we were absolutely adamant that we did not stratify people.
by what they were addicted to. So gambling, cutting, sex, cocaine, it doesn't matter. Nor did we stratify people by age, socioeconomic status, and there was a pressure to do that. Because certain other people who had more resources, right, like wanted that. Not realizing that what they were asking for was the very thing that was going to stand in the way of their ability to get help.
You told me this exact story when I called you up to say, wait a minute, I don't think the bridge is the place for me. And I should be going to this place or that place. And you said, no, what you're missing is you absolutely need to be around people who on the surface, you think you're different from to realize that you're not.
And it's an advantage that people have if they're at a stage of life, or for whatever reason, they're not in a socioeconomic class that allows them to differentiate, because they don't strive for something that stands in their way. And I think back on that venture, which over about five years, my partner and I, and we had 30 people or so in some way, shape or form, or we're working for us by the end,
We all like really slaved away to make that place as good as it could be. And when I think back on it, you know, I think the proudest moment, people have asked me this like, oh, that was so difficult. And those are people who know me and kind of know what we struggled through. And like, some people ask, what do you feel good about, right? And the same image comes to mind is I remember, you know, a young woman who I think she was 19 who really had struggled and was trying to find her way and had been on the streets.
you know to the outward look of things you know as piercings and tattoos and all the kind of things that kind of mark her attempts to differentiate herself to say okay stay away from me in a way that she was using to separate herself and God she had made so much progress so much progress in embracing who she was and not feeling ashamed of who she was and not feeling responsible for things that happened to her that she had no control over
And I remember her, I walked by late one day after groups had let out, and she was having this really intense conversation with a neurosurgeon, and it was so clear that she was teaching him a lot of things, and he was in sort of wrapped attention.
And it's a marker for me of like our shared humanness is like, you know, if you look at him and you look at her, you say, okay, the things they've achieved clearly she's the authority. He's got a CV a half a half a mile long, right? And you know, this woman has been struggling to stay off the streets. She had done more work on herself. So she had a lot to teach him.
And I have found that again, it sounds trite, but the things that I have learned through the course of my work, so much of them have just come from people who have been through such difficulties and have learned things about themselves that I hadn't yet learned.
not at all tied to any metric other than that. And I think that's part of the secret of it. And we don't do these things anymore. We don't have places where people can come and even get some mental health education, some idea of what else them in terms of trauma. We don't as a society acknowledge this.
So then it becomes some shocking rarity when somebody finds their way to it. And I'm astounded by that. That we should be setting a road map with really gigantic arrows for all of us. But a person has to stumble upon it or come across it inadvertently.
And in many ways, I think I'll forever be grateful. I mean, forever be grateful to you for making this happen because I guess some people just, they need a greater degree of immersion to finally break down. I think I could have spent two hours a week in therapy for the rest of my life and never, never come close to what finally takes place when you're doing 13 hours a day plus 12 step meetings.
And not only that, it's like every meal. You're sitting there with the same group of people. We only got coffee once a day. 7 a.m. was coffee time. And it was like, I would get up at four and work out. And then I'd be waiting to have my coffee at seven. And there were like six of us that showed up for coffee every morning.
The other thing about this place that was so amazing, which really ties into what you're saying is everyone who works there, obviously not just the counselors and the therapists, but the kitchen staff, the custodial staff, the people that worked at the barn where we did equine therapy, every one of them had themselves been a client there. Wow, I didn't know that. Unbelievable shared experience. Like we are all the same at this place.
Wow. And isn't there comfort in that, right? Absolutely. How can you be some exception who deserves shame for being something less than perfect when you fully apprehend that reality? Can't be, right?
You know, you said something a moment ago that made me think of one of my favorite talks. So, you know, you and I, you know, that I'm the biggest fan of David Foster Wallace, this person who I've just, I've just always been kind of so amazed by his insight. I just, you know, here's a guy who was not a trained psychiatrist. He's a writer. And yet his insights into humanity go beyond almost anything. I think you couldn't learn this stuff in a textbook and
You know, I've been asked before, like, if you could bring anybody back from the dead, you know, of recent era, right? Who would it be? And I think it would be him. You know, if I could go back in time and spend a day with anybody, it would probably be with David Foster Wallace. He has a very famous commencement speech from 2005 that he delivered at Kenyon College titled, This is Water.
And in it, he talks about the fact that we're, I think the way he describes it is, there's no such thing as atheism. We are all worshiping some God. Do you worship money? Power? Your body? You know, your physical allure?
And he almost makes the case that at least if you pick a God to worship, the harm to you might be less. Because if it is money you worship, you'll never have enough. If it's power you worship, you'll never feel strong enough. If it's intellect that you worship, you'll always feel like a fraud. And I remember listening to this for the very first time, which was many years ago in thinking,
Yeah, I get that. I really get that. I know I'm not alone, but I think a lot of people who place their self-worth and their intellect, you think, what if people find out I'm not that smart? I'm just a fraud. Again, it just speaks to this entire nature of humanity. Of course, the tragedy in the case of David Foster Wallace is that he ends up taking his own life by suicide three years after he gave that talk.
Not totally unrelated. I want to play something for you. So I was actually just listening to this today. I hadn't come across this before but this is an interview with David Foster Wallace and Terry Gross from NPR. I believe it was 97. So it was like a year or two after Infinite Jest came out. So I want to play this for you if I can cue it up on my phone here. Because I thought of you as soon as I heard this, right? Okay, here we go. You know, I really like the way you talk. You write about a pleasure.
and how difficult it can be to really achieve. You write about pleasure in the Infinite Jest, your latest novel. And I'm thinking, you know, one of the things relating to that in Infinite Jest, one of the characters finds that marijuana is no longer a pleasurable experience. It just makes him terribly self-conscious and therefore anxious. And I'm wondering what happens to you when you do something that's supposed to give you pleasure.
And it just makes you uncomfortable or anxious. Boy, I'm not really even sure how to respond to that. Look, a lot of the impetus for writing Infinite Jest was just the fact that I was about 30, and I had a lot of friends who were about 30, and we'd all been grotesquely over-educated and privileged our whole lives and had better health care and more money than our parents did. And we were all extraordinarily sad.
I think it has something to do with being raised in an era when
Really, the ultimate value seems to be, I mean a successful life is, let's see, you make a lot of money, and you have a really attractive spouse, or you get infamous or famous in some way, so that it's a life where you basically experience as much pleasure as possible, which ends up being sort of empty and low calorie. The reason I don't like talking about it discursively is it sounds very banal and cliche, you know, when you say it out loud that way.
Believe it or not, this came as something of an epiphany to us at around age 30 sitting around talking about why on earth we were so miserable when we'd been so lucky. Well, when did you realize that all the benefits you had in an educated middle class life weren't bringing you happiness?
Well, look, I guess it sort of depends on what you mean by happiness. I mean, it's not like we were walking around fingering razor blades or anything like that, but it just sort of seems as if we sort of knew how happy our parents were. And we would compare our lives with our parents and see that at least on the surface, or according to the criteria that the culture lays down for a successful, happy life, we were actually doing better than a lot of them were.
And so why on earth were we so miserable? I don't think, you know, I don't mean to suggest that it was, you know, a state of constant clinical depression or that we all felt that we were supposed to be blissfully happy all the time. There was just, I have a very weird and amateur sense that an enormous part of like my generation and the generation right after mine is just an extremely sad sort of lost generation, which when you think about the material comforts and the political freedoms that we enjoy is just strange.
I could listen to interviews with David. Well, indefinitely, but it's interesting that I came across that today for the first time. Again, I don't know how I missed it today, just literally today. And, um, you know, I knew that we were going to be speaking this evening. And I thought, you know, I'm going to put Paul on the spot and play that forum and ask him not just to explain that, but even more broadly, what the heck is going on? Right? Why? I mean, let's take a step back.
It would seem to me that suicide is the least likely cause of demise for our species, just given our evolution. I mean, it seems to me that we are wired to survive. So in other words, and again, I'm certainly not being critical of suicide. I have nothing but empathy for obviously anyone who commits suicide. It strikes me as the saddest thing ever.
but I don't understand it. I don't understand how it can be so prevalent when we must be so wired to not want it, when we must be so wired to want to survive. I remember very recently, I remember having this thought probably in the wake of these high profile suicides, which I remember when Robin Williams killed himself, the same sort of thoughts go through my mind, which is
Did our ancestors do this? Is suicide a symptom of our civilization? Is what David Foster Wallace is talking about here, even comparing ourselves to one generation ago, are we less happy or do we just have greater expectations? And those expectations being unmet is what makes us feel unhappy.
Again, it's so complicated and I want to start off by saying, by no means do I attest to any expertise or a right to offer an opinion that's more valuable than anyone else's. But the thoughts that occur to me is we're wired to survive as long as we see meaning in survival. And I am not here trying to glorify struggle.
But there is something around struggle that gives meaning. You know, people who struggle to survive in war zones, you know, are people who see meaning in survival. They see meaning in what they're fighting for. You know, Victor Frankl writing an immense course search for meaning, right? It's like, if you don't have meaning, then why would you struggle to survive?
And it's not a lengthy extrapolation of that to say, if you don't have meaning, why are you interested in surviving? Have you read Tribe by Sebastian Younger? I have not. I probably should. And I've been told several times I should. I just haven't gotten to it yet. But I mean, I understand. I think this is sort of part of what he's getting at. Yeah.
You know, that we, like, okay, for example, like, I really, I mean, it's interesting, right, given what I do for a living, that like, I don't know how I value myself. I don't know how to value myself and whether I'm succeeding or not. I mean, is that what my family of origin thinks of me? How much time I spend with them?
I've certainly ranged far afield and left the place I grew up in order to achieve things and do things. I should be proud of that. Have I not been a good friend or family member to the people I grew up with? Do I value myself?
what other people think of me, how many patients I feel I can help, the health of my relationship with the people I love as adults, the kind of parent I am, the kind of husband I am, how much money I have, how many people want me to offer some expert opinion on something. It's like I have no idea, I have no idea whatsoever. And it occurs to me sometimes that
I'll bet all those ancestors of mine really knew how to value themselves, like, are the sheep safe? Is there a roof over our heads? And again, I'm not glorifying the lack of opportunity, you know, the lack of like basic medical care, right, in generations past. But there is something very, very concrete about that.
And when people go through struggle, when we often most worry about them is when the struggle is over. When people feel like, I made it through that. Whatever that was, maybe that was chemotherapy. Maybe that was the death of someone close to them. Maybe it was a particularly trying time at home or in their career. People will persevere when they see meaning in their struggle.
But when there's not a struggle the struggle is over or we're not particularly struggling for something what does How do you value yourself? And I think often we don't even know enough to answer the question I mean like even I've never sat down and talked about this we spent a lot of time together We've been closed for two decades like why do we not talk about this in part because we don't understand how meaningful it is right so so we value ourselves by Persevering but that's endless
I mean, as you said, there's always more of things to have. So at a certain point, that can seem very, very hollow. And I think that in many ways, that's the disease of the modern civilization. I mean, even when we grew up the time of the Cold War, I grew up with this very clear idea. And I get that it was a simplistic idea. The West is good. And we fight for democracy.
You know, the Soviets are bad. And look, I get that this is not the case. I mean, I've spent time in Russia and in Eastern Europe and like, I get like the people or people, but it was an easy, it was an easier algorithm to grow up in. And it instilled faith in America and faith in what we stood for. And as we get older and wiser, we all learn about the hypocrisy of life and the
the truths of life and learning. I remember learning about things that America had done in Central America and feeling a sense of like, oh my God, we are not the source of good. And it doesn't mean that we were a force of evil. It means that the situation was far more complicated, but it provided a heuristic.
And even that was something that kind of made sense. I mean, I can remember the Olympics coming around and feeling this sense of, okay, are we going to beat the East Germans and the Russians? And there was just a sense of dichotomization, which is why people who want to control other people know to make struggle, right? You make an enemy.
So this is all a double edged sword, and you can make meaning in ways that is not valid, right? You say, okay, those people are bad, let's go kill them. I mean, that's a way of making meaning for people. It's not an honest or a moral way. But what I'm trying to point out is that we see value to our struggle if we see meaning. And I think that for a long time, even as people got wisdom and greater knowledge of things like hypocrisy and the really the truths of the world,
I think we still saw greater meaning. And I'm not so sure that we do as much now. I think that things are much more nebulous, and then it's hard to get around the idea of, well, do I really matter? What am I doing? What am I standing for? What's really the difference?
And I just think, look, that can happen at any time and probably did happen, you know, back, you know, when everybody lived in caves. But I think we're much, much more susceptible to it because we don't have some sense of community, right? We don't have a sense of community. I mean, it's interesting, right? People have written about why do human beings, when we're so focused on survival, right? There's a lot of people that will spontaneously risk their life for somebody else. Jump into the river, right? Try and rescue somebody. Why do we do that?
And the answer is because in that moment, we see very clearly defined, a very lucid meaning to our actions. And I think that that's very, very profound. And I think it's the opposite. I see that as the opposite of suicide, which can happen for a lot of reasons. People can be very depressed. And the delusions of lack of worth, I mean, again, it's very complicated. I'm not trying to trivialize it.
But I think a lot of what promotes suicide is the absence of meaning, which I see as the opposite of someone who's taking good care of themselves and he wants to stay alive very much so, but will risk their life to help someone else. That's a focus of meaning, that there's a compelling meaning right now. Right, what parent wouldn't jump in front of a car to push their child out of the way?
And a lot of those parents who want to be there for their child would jump in a river for someone else as they see a child. So, you know, it's that just capturing of the attention. Like, this is meaningful. Look at this. I will make a difference now. And I'm willing to take a chance to do that.
And I think it's very, very different than how a lot of people feel. I think also socioeconomic demographics. I mean, if you think that I don't know what the exact numbers are, but you know, what percentage of people in this country, you know, I was sort of reading the reports around like a $500 unexpected bill, right? And like, just people can't survive that, right? Like they're not going to get medical care. They're not going to
You know service the car and then they can't get to work or they're not gonna You know they can't live a life that we would consider acceptable You know with an unexpected in the grand scheme of things Otherwise surmountable amount of money that's needed and you know I think that's a very very hard way to live that that you know a lot of what we're talking about is
Foster Wallace was talking about of like, well, we have so much opportunity and we don't have to struggle, right? But if you're struggling to put food on the table and you know, you know that if somebody needs to go to the emergency room, how the hell are you going to get enough food, that's a struggle. It's very hard to see meaning it. That's a struggle that seems like denigration.
I mean, it's a struggle, whereas it's different. Our ancestors, if they had to struggle through a famine or drought, I mean, it was just that was just that was the gods, right? That was nature. That was the season and they were in it together. Right. And it's not like you were struggling because of the drought, but your neighbor was, you know, rolling around in a, you know, whatever the equivalent of the Ferrari would be.
Right, and I think even if it's so, you know, it's so in a way baffling, right, that, look, I hate the thought that how many people are there, that a 500 yard medical bill that can't put food on the table, you know, yet, you know, I'm fortunate to live in relative plenty compared to that, but I don't know how to bridge that gap. There's not a sense of community, and sure, like, we can donate and we can do things for free and all of this, but
But look, we don't have a sense of what does that mean? And how do we change that? And how do we make that better? And my sense is that I actually feel quite insecure. Do I have enough if my kids need something? Do I have enough if things really go south and it becomes unsafe to live here? I have a sense of vulnerability. What does someone feel like who has the same sense of conscientiousness towards the people that they love through $500 can sink?
So I'm not trying to make specific points about that, but really to point out what I view as just a tremendous sense of isolation. And it's not a disease of plenty. I mean, I think it's a disease that affect people who have enough and that affects people who don't have enough even worse. And that lack of shared sense of community, a lack of being in it together, you know, it may sound hokey, but through most of life, that's how people lived.
I mean, unfortunately, Paul, everything you just said doesn't really seem to offer a foreseeable remedy to this. And if today we're seeing 30% more suicide or thereabouts than we were a couple of decades ago,
Is there anything on the horizon that's going to curb that trend? Or is suicide going to become an increasingly greater part of our humanity? And perhaps worse yet, for every person who actually kills themselves, what if there's nine people who are in that category we described earlier is basically functionally dead? And then you think of the effect of the suicide. Exactly. What's the trickle down effect of that on the next generation?
I do think that there are ways to make this better, and I feel strongly and passionately about them. You and I have talked about some of them, and I'm fortunate to have dialogues with people who can really help make a difference in this way. Again, do I know that it's the right way? No, I don't, but it's the best I can think of, which is
It's a simplification. We don't have places where people can come together and have shared experience and have a sense of community. What about places where there are people to facilitate human connection and education, even about the basics of what's going on inside of people, and there's a couple of comfortable couches and a pot of coffee? These are not expensive things. You think about it in this country,
What things cost go get an x-rays $700 right I mean we've built up so much cost around things so much liability so much that prevents really basic simple things from happening and we've lost the basics of community support.
I mean, there was an era before you and I were practicing medicine, certainly before I was a psychiatrist, right, where there were community support centers and they were publicly funded and they didn't cost very much money in the grand scheme of things. And there were places where people who were pretty mentally ill could go for support. Not only do we not have places like that for you and me and the other people who are managing to function, we don't even have those places for people who are really mentally ill.
So we don't provide a nitis in the community for the basics of what I would call psychoeducation and for the ability to do that in a way that really links human beings and looks at what their needs are. You know, how many times have I seen where a person who, if they overdose or they slit their wrists, right, that the world will pay
a million dollars for their intensive care unit stay. But what we will not do is buy them the $300 alternator that could fix the car that allows them to not have to go back to the abusive household situation that leads to the suicide attempt that society pays a million dollars for.
A lot of what we do is utterly absurd as a society. It's not even cost-efficient. If you took out caring concern for human beings and said, let's factor that out, it's absurd. It's like you'll throw away $10,000 to get a dollar. And that's how we operate as a society. And I think that if we're going to survive
our own progress. As a species, or certainly in this country, we're going to do things that are around mutuality and community support. And we're going to do things where people who have something can help people who don't. And maybe that's $300 to buy an alternator. Maybe it's not that. Maybe it's somebody who doesn't have the education and resources that you or I might have who shares some wisdom that they've learned. I mean, it's not just
The people who have do things for the people who haven't I mean we all have and we all don't have and I'm not trying to trivialize the struggles of people who Can't put food on the table like that's we need to work so that that's not the case and it's actually not that hard to do but at the same time we need to recognize that
that some of the things that we've done through drive to separate us make us lonely and isolate us. And I think you and I have as many emotional needs and as many struggles that can be soothed by other people as somebody does who might identify as underprivileged or ill. Like I said, we're all in it together.
But we work so damn hard to separate ourselves and you end up with maybe not everybody but most people feeling some sense of loneliness and isolation. There's no easy antidote. You and I have spoken a lot about.
the idea of creating a tribe. We think about the seven of us from medical school and it was like we had this fantasy like what if we all could get jobs not only in the same city but like we could all live in the same block.
And we could all just sort of be one family. The kids could go between the homes interchangeably, meals were consumed interchangeably, like it was just, you know, creating a tribe in the way that it would have existed 10,000 years ago. But, you know, we still put our shirts and ties on in the morning and go to work. But you, but there's this closeness that seems so distant right now. I mean, you and I are so fortunate because of the geography in which we work that
At least a few times a month we get to have a meal together. But that is harder and harder to do with friends. And I suspect that there are many people who go months if not years without really getting to do that. Because it's just too busy. There's just too much to do that's mission critical.
Right, and there again is the automaticity of a value system that, you know, I struggle very much with how many people do I care about who've been really important in my life and I think in I and theirs that we exchange to emails a year. I mean, why?
Why do I not take two weeks every three months and go around and see people I care about? Like, why don't we do that? And I think, again, I do think that all paths, I mean, not all paths, but I think the majority of these paths lead back to trauma.
that there's a way in which I feel too insecure to do that. I'll step away from my work, and maybe I won't be as good at my work, or opportunities will pass me by, and I'll earn less, and all these things that actually make no sense whatsoever, but it's not as if I can stop them from driving me.
And I want to sound futile about that. I think there are things that we can do. And I think you and I do some things that we might not have done even a couple of years ago. But do I think that we do enough of it? No, I don't. And you think about those other people that we were in school with and care very much about. And then think about people who weren't in that group that we knew well and care very much about. How much do we really see of them?
almost nothing. And it's a strange thing to have so much automaticity to our value system. And we might think, well, I never decided I don't value that and I value another day of work overseeing those people.
Okay, I never actually put words to it, but I've decided it, right? Because I act in accordance with that decision. And yes, I'd like to be healthier about those things. But I think the answer is as a community that we start teaching ourselves and teaching people how to be healthier about those things. Because you can still be very good at what you do, very successful, move society ahead, all these things that we want to do if we achieve and have a better sense of balance and mutuality.
which is why a lot of these fantasies. And that's what kids say in kindergarten to their best friend. Like, we're going to live next door to one another, right? Okay, we're still saying that medical school after. Yeah, we're freaking 45 year old dudes and we still say the same thing. Right, because I think we still have the same needs within us. And we still have the same fears of loneliness and isolation and struggle and isolation.
So the fantasy is still there, I think, because there's meaning to the fantasy. It's a recurrent fantasy in a lot of people that tells us something about our desperate sense of isolation.
And I have no basis to back this up, and it probably is politically incorrect to say this, but I actually don't give a shit. You can be married, you can have the perfect spouse, you can have all that stuff going on. But when I say this only being able to speak from my vantage point, which is as a male, I think that there are certain needs that can't be met by your spouse. There are certain needs that like, and again, I think my wife doesn't even like hearing that. Like she'd like to believe, understandably, that
every problem i have emotionally can be rectified by discussing it with her but i do think there's something different that i think there's a big maybe even a degree of vulnerability that exists outside of that relationship and or maybe even there's just something gender specific like a guy needs to be with a guy sometimes a girl needs to be with a girl sometimes as far as like
Truly talking about some of these things and i think that for many people as they get older as they have families as they have kids as they have careers. They lose sight with those other people meaning the woman loses touch with her female friends who i think can offer her something that her husband cannot even if they're the most well adjusted couple.
And similarly, I mean, I can't tell you the premium I place and the time I get to spend with my male friends. And it's hard because as you said, it often comes at the expense of time with your family. I mean, every minute I'm here in New York right now, you and I are here. We're not with our families.
I mean, I think that that is a human problem. I mean, I think that we see it through our own lens, right? But I don't think it's based upon gender, socioeconomic class, sexual orientation. I mean, I think it's a human problem.
that there's a fallacy that says that we're supposed to enter, you know, a committed relationship, which already think about what there are people who, you know, might not be able to do that, right, might not want to do this. So we're already saying, de facto, that that's not okay. So I think how many people were invalidating already. Then we say, okay, even if you do that, we're gonna put so much pressure to be everything to one another.
that we guarantee almost a sense of a failure or of inadequacy. Why should your lovely, wonderful wife think that she can be everything to you? That's just not how humans work, but somehow society is told her that, and then it engenders some negative feeling because both you and she, being healthy people, need a broader set of connections.
But we're taught to kind of hunker down and that's what we're supposed to do. And then when we're getting away and we're doing these things with our friends that there's something about that that seems kind of trivialized because we don't live in communities. And look, think about it. I haven't thought about this before. We think about in medical school when we were kind of living in a community.
And we did spend time, like, if we were friends, then I spent time with Jill, and you spent time with Brooke. We were in a community, so there was more of a sense of communality. And now, we don't have that as much. Like, that's not the way it's supposed to be, in a sense. And then it engenders these unrealistic expectations of self and others. And the question I would most ask about that, I don't know the answer to, is like, why don't we continue to live
