Hey, everyone. Welcome to The Drive podcast. I'm your host, Peter Atia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen. It is extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members, and in return, we offer exclusive member-only content and benefits above and beyond what is available for free. If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to petereatea. Md. Com. Com/subscribe. My guest this week is Paul Conti. This may be a familiar name to many of you, as Paul has been on multiple times and was one of our first guests way back in September 2018, back on episode 15. Paul is a practicing psychiatrist and author of Trauma: The Invisible Epidemic: How Trauma Works and How We Can Heal From It.

He's a graduate of Stanford University School of Medicine, and he completed his psychiatric training at both Stanford and Harvard, where he was appointed chief resident. He then served on the medical faculty before moving to Portland and founding Pacific Premier Group, a practice focusing on addressing mental health from a trauma-based perspective. In this episode, we speak about emotional health and its relationship to lifespan and health span. Through this, we try to look at the various ways listeners can take an audit of their internal and emotional health, knowing that this is one compartment of health span for which we don't have biomarkers and for which we don't expect an inevitable decline as we age. We cover how emotional health can also increase with age, what drives people and their motivations, happiness and satisfaction as it relates to material possessions, the connection between physical and emotional health, negative self-taught, accepting death, and more. We end this conversation speaking about how people can take a first step in improving their emotional health and what people can look for in a therapist if they deem it necessary. So without further delay, please enjoy my conversation with Paul Conti. Paul, so great to see you again.

It's never frequent enough. I agree.

Thank you.

So I don't know, somehow, the evolution of my thinking on longevity, I feel more and more drawn to health span over lifespan. And again, not that these are ever mutually exclusive. They're not. And virtually without exception, anything that's enhancing health span is enhancing lifespan. I think it's just a question of focus. And I think when you focus more of your energy on health span, you're getting a lot of those lifespan benefits for free. And you can clearly do a lot of the one-off stuff that is purely lifespan-related, like managing your APO-B and cancer screening and things like that. But it's this focus on cognitive health and physical health that get you so much of that lifespan benefit. And of course, you're enjoying the quality of your life. Those two decline quite predictably. And so really what we're trying to do as we age is delay the rate of decline. But then there's this third component of health span, which is emotional health, which is what obviously we're going to speak about in great detail. And what I tell people and what I tell myself when I'm feeling a little depressed about aging, is that the thing we have going for us is that's the one that doesn't have to get worse with age.

Everything else gets worse with age. You can do quite a bit to mitigate that and reduce the magnitude of the negative derivative, but you're not making it a positive derivative. But this doesn't have to be true for emotional health. I want to ask you just to start, in your experience working with people, is that what you see? Do you see that people generally become happier, more satisfied as they age? Do you think that's the exception? Is it the rule? And I guess as a It's all up to that, how deliberate does one need to be about emotional health to ensure that you can reap what I just said, which is, hey, you could actually be on an increasing curve of emotional health as you age.

I think, unfortunately, emotional Health often declines as people get older. That is the rule, but it doesn't have to be. I think that that can be the exception, and emotional health can improve throughout the lifespan. But there's so many things that we have to be aware of. As you said, does it take intention? Yes, we have to really think about how are we taking care of ourselves? How is my emotional health setting the climate for my physical health, my cognitive health, for my happiness. Very, very often, we get swept up in this idea that, Oh, time is passing and we're getting older and isn't that bad? There's a whole set of societal standards that bias us away from good emotional health as we get older. I think this idea that it's so sad that we're getting older and we lament it and we talk about how fast time is going, I think that's really a societal construct. It's a social construct that we can change Because if we're actively taking care of ourselves, and this means, yes, it means, of course, taking care of our bodies so that we can remain active. It means remaining interested in new things.

It means learning. It means keeping an expansive mindset that if we're doing this, we're setting a climate inside of us that is conducive to all these other good things, to health span, lifespan, cognitive health. But so often we're trying to do that, or we say that we're trying to do that, but we're ignoring the climate that we're living in. We do have so much more control over that. I think that's part of the message of health span and lifespan is attend to our emotional health, take it very seriously, because we're living in it day in, day out, and we've got to step back from our lives often and look at what are we presuming? Are we thinking, Oh, it's just bad to get older, and the jokes and all the dialog within us is negative? Or can we feel good about getting older, that we have achievements under our belt, and we have learning and wisdom that we didn't have before. We can continue to stay curious and active and get happier and healthier across the lifespan. There's a demographic of people for whom that's absolutely true, and it's wonderful to witness them. They're very, very different than people who are not like that, where you see people aging and they're still bright-eyed, engaged in the world, and that doesn't happen by accident.

Let's talk about emotional health in the sense of how it fits into health span. When someone asks me to explain what the cognitive component of health span is, we can talk about executive function, we can talk about processing speed, we can talk about recall memory. Of course, you can drill down further and further and further into these things, and you can start to paint a pretty comprehensive picture of what cognitive health involves. And you can also do that cognizant of the changes that occur. So Arthur Brooks has written quite eloquently about the transition from fluid intelligence to crystallized intelligence. And so while our fluid intelligence peaked when we met each other, and we've, in that regard, only become stupider, we've gained other intelligence, this crystallized intelligence that's more experiential and more about pattern recognition. And while we might not have the processing speed we once did, we're intelligent in a different way. Similarly, on the physical side, and I should say one other thing, Paul, we test these things. These are all testable. These are quantifiable things. And while most people don't necessarily do it, it can be done. We do it with our patients.

You go to the physical, it's the same way. I could spend the next five hours talking about the nuances of strength, power, explosiveness, cardiorespiratory efficiency, maximum cardiorespiratory... Flexibility, balance, all of those things. And yes, we can measure all of those things effectively, and we can track progress and things like that. I have a definition for how I think of emotional health, but I would much rather hear yours. How would you explain the umbrella of a person's emotional health? And then I'll plant the seed, which is where I want to go with that is, given that we don't have biomarkers for these things and necessarily tests that we can do, I want to talk about how we can evaluate it.

Sure. The way we evaluate it is by looking inside. So then what are we looking for inside? We're trying to understand what's going on in us. When we wake up in the morning, how do we feel about ourselves? How do we feel about life? Are we low-grade afraid? Do we feel on the back foot? There's so much of this going on in us, and then that impacts our self-talk, which is why we may not have biomarkers, But we can look inside, so to speak, by asking the right questions. What do you say to yourself when you're alone? What phrases or mantras seem to repeat over and over? Do you criticize yourself? Do you have a shadow voice within you that is oppressive or that is regretful or that is ashamed? What is going on inside of us is often very opaque to us, even though we're living through that when we then interface with the world. So this idea that if we inquire, if we become curious about ourselves, we learn so much more about what is going on inside of us, and it can guide us towards change. So if a person wakes up and doesn't feel good about waking up or feels afraid or feels ashamed, why is that?

What can be done to change that? Because very often, the environments inside of us we're not taking good care of. We, for example, harbor traumas within us that we haven't talked about or processed. It's one example. Or we know that we don't feel great, we don't know quite why, and then we're afraid and confused and we move forward. This idea that we should be as interested at what is going on inside of our minds, what is going on inside of us emotionally as we are about our bodies, even though we have many more markers, biomarkers, internal and external, to look at physically. Sometimes what I'll see is a person is paying a lot of attention to that, but it's all couched in an emotional climate that is not good and that at times becomes angry and aggressive. Like, I'm going to fight aging, and I'm not going to let this get the best of me. And that's not a recipe for happiness and health. There's so much acceptance called for. So acceptance of the fact that we're aging. So you're right. When you and I met, we had much greater processing power. That's great. We could sprint better, say.

But life isn't a sprint. It was fun to be able to sprint when we could sprint really, really well. But I hope and believe that we're both smarter now, even though if we stop and look at our processing power, we can see the change for the negative. But that's one factor that's negative. Overall, I think and hope that we're wiser and happier, but we have such a bias in us, a salience bias towards the negative. We look and say, Oh, look, I could do so much more before. I could hold so much more in working memory. I was so much faster. Look, I'm getting old. Okay, the trade-off for that of increased intrinsic knowledge, things we know without having to think about it, that reside in our unconscious mind, we don't value that as much. I think if we can get over some of the biases that come from outside of us and then come inside of us, both that our emotional health maybe isn't so important or that there's something that's not so high yield, paying attention to that, or even that it's weak to pay attention to that, instead of seeing that's undergirding everything else that we're doing on top of it, let's pay close attention to that and let's be interested and curious about ourselves.

Because that's where it leads us, is to be curious about what is going on inside of me. How is it affecting me? How are all these things I do from morning till night affecting what's inside? And how's what's inside affecting that? Or things I want to change or do differently. Now we become curious and engaged, and we want to learn, which is a characteristic of being younger. People want to learn and think expansively, and we're interested in new music and new sights and sounds. If we can maintain that, that curiosity capacity about ourselves and about the world around us, then we change this really, really big factor that often is working against us, and we're not aware of it. By looking at it, we can control it and make it work for us.

Where do some of these other things that I think of, at least, and certainly others, fit into the overall equation. So I'll give you three things that are probably subsets of that, and I want to think about how you integrate them. So one would be something that's talked about a lot, which is sense of purpose. I think there's so much literature on this, in as much as there's literature in this field, which is obviously harder to do this type of work. But you say to a person who's working hard but down and out, Hey, would your life be better if you won the powerball today and you never had to work again? And the data are pretty clear that the answer is no. If you didn't have something to do, and it doesn't have to be the job, but if you don't have something to do, if you don't have a purpose, it's very difficult to have an emotional keel that's adequate. So sense of purpose would be something. Another thing would be this idea of satisfaction. So achievement following struggle. And again, I think anybody listening to us right now can relate to that.

Achievement with no struggle is not particularly satisfying. Arthur Brooks, again, has talked a lot about this idea that satisfaction is sadly fleeting, but nevertheless, it temporarily provides a positive feeling that is worth reinforcing. And then obviously, what you're, I think, talking a lot about is relationships, too. So what is the nature of our relationship to self and then the quality of our relationships with others? What else would you add to this, or would you subtract anything from it?

I think the first thing I would do is take the extremely important things that you just said and put them under the heading of a generative drive. The field of mental health has long understood that we have drives within us, and it has been focused on an assertion or an aggression drive. Drive, which makes sense. We have to do things in order to survive, in order to achieve, in order to move ahead. So there's an assertion drive within us.

This must be highly, highly preserved. Natural selection must have been ruthlessly selecting for this.

The thought would be, it would be very, very hard to survive without either one of these, especially in an era of human development when one took a significant amount of responsibility for one's own survival. That one had to be assertive. You had to want to impose yourself on the world around you. So assertion or aggression, whatever we want to call that drive, it's a drive to do in the world. And then there's a pleasure drive, which at times has been misunderstood, that it's a drive for hedonism. But pleasure comes in all sorts of ways. Pleasure comes from being inside out of the rain. Pleasure comes from being warm and not cold. Pleasure comes from having enough to eat. So pleasure drives us not just through sex satisfactions that may get more attention, but through relief of pain, through a sense of safety, a sense of security. So we're very, very focused on humans in the field of mental health, which is guided much, not all, of course, of our understanding and our beliefs about ourselves. We see assertion, we see pleasure, but that ignores the humanity inside of us. If that were true, how differently would we behave?

People wouldn't create for the satisfaction of creating finding something new or go somewhere new because we don't know what is there. This is humans going deep in the ocean, climbing mountains, going to the moon. There's something else going on in us. That other thing is the generative drive. As of philosophy and literature and religious studies and psychological studies point us in this direction, but the field of mental health doesn't acknowledge. We want to live and create beyond ourselves. We, for example, may have children, not just so someone may take care of us later on and we perpetuate our genes, but how about for the joy of seeing the children learn and develop and be in the world and see them grow? There are things inside of us that are about creation and are about growth. When we are in touch with that, when there is an active generative drive, then we are on this path to happiness. This is the way to take care of everything, emotional health, cognitive health, physical health. It all comes together in some sense. It all naturally comes together if we're approaching life from a healthy place. To go back to your example of someone who is unhappy, say working, and feels like, Oh, I'll be happy if I win the lottery.

Why does the data show us that that's not true? Because the presumption there is the generative drive isn't satisfied by either scenario. If the person is working and they're not happy, then there's something there that could be, would be, probably should be different. Are they enjoying the work that they're doing? Is this what's really inside of them? What they value? Are they doing it just because they feel it pays them more money and they have to make more money? Do they feel that they need to make more money than they're making? And now they're unhappy and disappointed There's something in their work that's not honoring this, ultimately, I believe, greatest human thing to make more than what we are. The contrast to that is not winning the Powerball. In fact, It's the same thing coming in a different disguise. It is now not honoring the generative drive. There's enough money, but there's nothing coming out of the person that's creative. If someone imagines winning the powerball, and then maybe they'll go back to school and learn something they really wanted to learn, or they'll go do this thing they really wanted to do, or they'll grow a giant garden.

If having the money that would come from the lottery win and having the time subserves the generative drive, then that is a good thing. But money alone doesn't provide that. That's where inquiry could come in. What is going on in this person's life? How are they working? What choices are they making and why? What's inside of them? Do they feel good about what they're doing? Do they want to do something else? We see examples of this so often where people are out of a cord with themselves and they're unhappy, and then there's a sense of futility about it. I'll get out of this if I win the lottery. That's not the answer. There are many things we can change in our lives. You and I know this. How many different things have we each done across the lifespan, some of which we then incorporate going forward and some of which each of us has decided to move away from. And I think some of that is honoring the generative drive of if I'm not feeling a certain way when I'm getting up in the morning, what is it that I need to do differently to feel that way?

Paul, do you believe, I know this is not knowable, but what is your belief around the innate nature of the strength of the generative drive in an individual? So if you look at a thousand children that are born across very various cultures, socioeconomic status, different races, look at all factors, and what is your view on the innate strength of that drive? Do you believe it's relatively preserved and that early life experiences shape it as adults?

I think there's nature and nurture aspects. It's wide-ranging across humans. But if we really step back within a relatively narrow band, when we come in close, we see that the drive that vary so much across people. But how we see that is also a factor of what the person has been through. Has a person been taught and told that their generative drive was worth something? Did their parents delight in things that were of interest to them? Did they feel nurtured or did they feel denigrated? Did they feel thought of as less than by the society around them for whatever reasons people do, whether it's race, religion, gender, identity, sexual, or There are things that push towards people feeling less than or feeling less capable, that the good things in the world aren't out there for them. So one aspect is genetic, that we probably inherit a whole set of factors that we don't understand that lead with a predisposition. Someone may be relatively satisfied with a level of life that might make someone else bored and needing something very, very different. But then our life experience, probably through psychological factors, epigenetic factors, even factors of inflammation running around in us and how that makes us feel physically based upon what's going on in us emotionally.

Now we have a whole bunch of factors that feed back to the natural genetics and impact where am I at any point in time, which is why we can intervene and we can help people to feel more of a generative drive. If a person feels disillusioned and disheartened, maybe there's some desire in me to do something different or better, but why? It's not going to happen anyway, or I'll end up feeling disappointed and worse afterwards. Can we help people be in the in a way that better honors what's inside of them and tells them they can understand and harness and change their lives in ways that bring them greater happiness. I think we all have a generative drive. It varies a lot among humans, but if we really step back and we look, we're probably selected to be within a relatively narrow range. Although as we get closer, that range seems wider and wider. What we can do is help ourselves to optimize whatever the range of genetic drive is within us because it's not set at a certain place. Through things like giving people opportunity or encouragement when there was none before, helping people with their mental health or their physical health, helping people with basic needs, basic needs of encouragement that often doesn't happen in, for example, our education systems, then we can help people be at the best place they can be.

I think that's the leader of all else. If we help the generative drive be as best it can be, where we want to be in the world and We want to see and understand and create whatever that may be, whether it's a garden or it's a company or it's a cure for cancer. If we help ourselves to live as best we can, then the rest of the aspects of our health will follow. I don't know anyone with a really strong generative drive who's engaged in the world who isn't also interested in taking care of themselves. This comes along with feeling that we can be the best we can be in the world around us.

Maybe I'm not understanding it correctly, but sometimes when I think of a strong generative drive, I think of a person who is striving so much, who is so productive in the eyes of the world. They're running three companies. They're successful by every metric you would have. But they're actually not taking care of themselves. They're working so hard that they're not taking care of themselves. That seems a little bit at odds with what you just said. Or have I misunderstood generative drive? I'm now talking about a pathologic state or a state that is harmful.

Achievement is not the measure of the generative drive. So there are people who are phenomenally successful in the eyes of the outside world and running three companies, and they feel great about what they're doing. They have great relationships with people around them. They're thinking as they're doing. They're taking pride in moving forward businesses or ideas in ways that wouldn't be happening without them. There's an engagement in life, and they feel productive. They feel worthwhile. They wake up with a good feeling. But there are people who look the same from the outside and are driven by shame or fear or previous deprivation, that there could never be enough so that what you have can't be taken away from you. There are people who are laboring under those fears, often from early childhood experiences. From the outside, they look very, very productive and successful. But on the inside, things are very threadbare or they're filled with fear. Whereas you can see a person who from the outside world is not doing very much or coming and going from a routine job, but they're growing a beautiful garden in their backyard, and they are filled with a generative drive, and they are happy.

What we see from the outside tells us something, but it's just data. It's like any other data. The data outside of context is not a value and in fact becomes misleading. I see this at times in people who are very successful, who don't understand why they are not happy because they are very successful. It should back map that they must be successful. But what really is going on, they may have a very strong assertion or aggression drive because they're running away from something, their own fears about themselves or shame or prior poverty or whatever it may be. That drive is very, very strong. Their enjoyment, their ability to take pleasure in all of it is very, very low. And then the generative drive inside of them is at a much lower level than it seems to be from the outside.

That's very helpful. And it actually, I think, probably answers part of my next question, which is, would it be your belief, again, knowing that this is not knowable, that everyone is, at least from a nature perspective, born with the capacity for enough generative drive to be happy later in life?

I think the answer to that is yes. I think, as you commented a little while ago, we're selected for that because that is adaptive. High levels of generative drive drive. This is the person who, in Hunter-gatherer days, would say, The food is a little bit sparse. There's a mountain over there. We don't know what's on the other side of it. Maybe we should check, or maybe we should do things differently so that we're better prepared for what may come next. The generative drive and the enthusiasm and the joy inside people when that is being realized, it does pull humanity forward. I think Leon Trotsky said that the locomotive of history is war. I would beg to differ with Trotsky. I think war and the aggression driven by human envy and destructive capacity is the opposite. It's not the locomotive of history. It pushes history backwards. What is actually the locomotive of history is the generative drive within us as human beings and our ability to realize it. This is why people learn and create. Imagine like Mendeleev in front of the periodic table and the joy of putting, wait a second, I see a pattern here and figuring it all out.

There is a joy in creation, whether it's watching a child or they can be watching something grow or discovering something. This is the locomotive of history, but we pay so little attention to it inside of us. Even the idea of valuing ourselves by what we see from the outside, by things that we feel bring us prestige. We know that that doesn't make happiness. We've gotten lost a little bit and a little bit away from what our core humanity is telling us is we want to feel worthwhile and we want to be interested in things around us and we want to be delighted by new knowledge and new experience. When people carry this through the lifespan, going back to where we started, these are people who are happy and who are taking care of themselves and who age well and who don't fear death. That's also another part of it is when people are living through the generative drive, they're taking care of themselves in mind and body and emotion, they don't find they're afraid of death. It's not that people want to die, they want to stay alive because they're healthy and happy. But there's a difference between that enthusiasm and fear.

I think that is remarkable. We should look very closely at who are people who are not fearing death. We see that they are often in very good balance. The generative drive is being honored and the assertion within them and the ability to feel pleasure and satisfaction. These are all well balanced. And then they're in places where they can find some peacefulness and some reflective capacity and some ability to feel contentment and delight in the world around them. I mean, we see this, and these are happy people, and we know that is not tied to the things we might think it's tied to, like wealth, for example.

So how can a person begin that examination. I think what you said is very insightful, which is from the outside, these can be indistinguishable. You can have an individual who looks like they are doing remarks remarkably well. Again, by any metric, I don't just mean financially, but I mean in terms of actual achievement. But it could be fueled by fear, by anger, by insecurity, by any of these other things. And you can have an individual who's achieving the same things or frankly, less, but it's coming from this generative place. So if an individual listening says, Hey, how can I take this first diagnostic step and evaluate my own drive, what would you say to them?

The first thing to do is to look inside oneself. How do I feel? I talk a lot about a life narrative. A person could just start writing, you can start talking with someone, you can start introspecting. There are ways of taking stock of what is going on inside of me. Am I being kind to myself? What's the voice inside of me saying to me? Do I feel good about any of this? Is any of this what I want?

Let's stop there for a second, Paul, because that's not an easy question to necessarily answer. I want to dig into this because it can be very difficult to answer that at a deep level, because sometimes the superficial answer is so obvious. If you have If you have everything, if you have material success, your knee-jerk answer would be, of course, this is what I want. How do you go deeper into that question to what you're talking about, which is the look inside?

Use more specific tools. So what What do you say to yourself when you're alone? Is there something that you say to yourself over and over? If you make a mistake, what do you say to yourself then? Is there an urge in you to be helpful to other people when you see them around you? If someone stumbles in front of you, do you feel like you want to move forward to help that person? These are the ways in. These are the ways to give us answers about how we feel about ourselves. There was a period of time, seven, eight years ago, where I would, for some period, a week or so, would see people who had very, very high levels of success, that from the outside looked as if they must be happy. When I would stop doing that, I came back and I would do clinical work on a unit that takes care of people who don't have insurance, many of whom are indigent, not all, who have drug and alcohol problems. So the opposite end of the socioeconomic spectrum, I swear to you that this is true. I could find no difference in overall happiness between the two groups.

So someone who looked to have it all would feel, if I don't have that next achievement, it all goes away. So the person isn't owning what they have earned for themselves. And this is a theme inside of me. So the person may have made a lot of money, and now they don't have to worry about being in need, or they may have achieved that their chosen art form, but they're so afraid that if the next thing doesn't go right, it'll all be taken away or they'll feel ashamed of themselves. This goes on a lot in people who are high-achieving. It's like, what have I done for myself lately? And if I haven't done something good enough, I can't feel good enough about myself. There is so much of that. Whereas I I would see people who from the outside literally had nothing, who would be saying, When I get out of here, I'm going to do it differently. I'm going to do it better. I'm going to go see this person I really miss who is helpful to me. I'm going to get a job. I'm going to keep myself away away from what got me in here in the first place.

They might have an enjoyable story or memory to say. I remember one point meeting someone who was living behind a bush under bad conditions who was far, far happier than the vast majority of people I had seen over the previous several days. The truth is we are often running from something or trying to achieve something that makes us safe in the world. And all of a sudden, we're going to feel better about ourselves. And what we really need to do is honor that we are human. And what is going on inside of us is so important. If we are willing to look at that, we're willing to ask the questions, what do I say to myself? How do I feel about myself versus other people? Do I feel like a fraud? Am I afraid everything will be taken away from me? Every time I drop something, do I say, what an idiot inside of myself? What is going on inside of me? Do I feel like I have an openness of spirit to new things or people who are different from me? We can ask ourselves these questions, but we have to stop feeling that what we adorn ourselves with is what brings us happiness.

Then we can get to this owning what is ours. That person who is going to try and put a roof over their head when they leave can own what's theirs, which is the tenacity to have what? Survived behind the bush, survived and lived in that way and maintained a good spirit. Often, these are people who are helpful to other people and are looking out for people around them. That is something to feel so good about as you strive for what comes next. Just someone who has worked and learned and studied could feel good about the achievements they have, or someone who goes to a difficult job that doesn't provide them with satisfaction, that they feel is backbreaking labor and underpaid, but they go and do that and they take home a salary that supports a family and puts a roof over people's heads. Feel proud of that. When we don't feel good about ourselves, often we are out of kilter with the generative drive within us. That is absolutely a part of what makes people unhappy. But also, coming along with that is not owning what is ours. And how many people who've raised families, done things that are so impressive from the outside, have told me over the years that, Oh, they're not worth anything.

They didn't make enough money. They didn't do this. They didn't do that. And it's not what matters. It is not what matters within us. It is being the best that we can be and honoring the drive inside of us to live and to create.

How would you make the case to somebody who's listening to this and says, Paul, I get what you're saying, but there's no way that if I had to choose between those two extremes, meaning I live behind a bush, but I have some happiness, but I have nothing, no material possessions, no status in society, versus I could be incredibly successful in the eyes of society, and with it, have all of the comforts that come from that success, all of the wealth. But you'll tell me that I'm unhappy. Someone listening to us might not be able to even wrap their head around what you're saying because they might be right somewhere in the middle. They're not living on the street, but they're struggling. And they believe that their struggle is because they don't have something greater. Or even they acknowledge it and say, Yeah, but if I had to choose between those two, I'd rather have all the comfort of the world materially and be miserable. It's a silly question, but how would you make the case to them that, A, it's not a zero-sum game, and that's a false choice, so we'll come back to that.

But more importantly, even in that extreme choice, why is that not the wise choice?

I would say get to know people in both categories better if you're in the middle, because I know what I would choose. I would absolutely choose that person who doesn't have any material possessions. If I were making the choice for myself, the selfish choice is to choose that person. I don't want to be the other person because I know that's not happy. I see where that goes. I see where the dissatisfaction leads, and I don't want that. I would much rather have within me the spirit that makes me feel like I can do something, I can make some change, because we all need the basic minimum in order to have some safety and satisfaction, like a roof over our head, enough to eat. But oftentimes, if you give a person a little bit of help, they can go off and do that. If I were that person getting some help so that maybe now I can move my life forward, I would feel an enthusiasm about that. I can make things better. I can have the minimum that I need. From there, what is it that I choose to build? When we look at measures of satisfaction, societies, even today, who are by and large hunter-gatherer societies or the societies that we, from the outside I think, have nothing, are often happier than we are.

So there's your proof. There is your proof. I think as a society, we have so much plenty that we can look after people better. I always say we live in a society that runs ahead so quickly that we're always trampling people along the way. And one, it's just not right to do. And two, any of us can be in that group of people who has something really difficult happened to them, was up against something really, really big, and then something else really, really big, and gets to a place where we need a helping hand up. And any of us could be that person or someone we love could be that person. And even if that weren't the case, it's just not right. Even Even if that weren't the case, it's not even economically efficient. Help people to be productive members of society. That's important economically. And of course, beyond economics is the human part that matters, but even just the dollars and cents of it tells us help people up when they need help. We can do more for people to give them an opportunity to make a life for themselves that can feel productive and contain happiness within it.

If we do this for all of us, we give all of us an opportunity to have the generative drive within us realized as that may be for us. Someone who's very interested in academic learning and success may think, Look, I like that. I like when I get an accolade. I like when I learn something. Then maybe they go off and they start building businesses and they feel great about that. That's wonderful. That is wonderful if that's what that person feels good about. There are also people who live good, productive lives and they're good neighbors to the people around them, and they take care of children if they've chosen to be responsible for children. These aren't people who should feel any less good about themselves. The irony in the world is that often what I see are both groups of people are not feeling good about themselves. They're not earning what is theirs. The person who went off and studied and created and kept feel good about the wealth they generated that now may be good for people around them, and they don't feel good about that. Or the people who struggled and worked and made good lives for themselves don't feel that they have enough.

I see this as coming along with this idea about aging, that, oh, we should feel so bad about getting old, and, Oh, we should feel so bad about whatever we can identify in ourselves that isn't what we think it should be if we look from the outside. There is a real simplicity in just sitting with ourselves and introspecting, or sitting with someone that we're talking to, or writing with a pen, or being in a therapy room of, Let me think about me. Because the truth is, all of us are so different as to be really and truly unique. If we take ourselves out of how we try and tether ourselves to all the shoulds around us and say, Let's talk about your life. Let's talk about what your experience of life has been, your experience of being in the world and trying to have some healthy control over a world that's difficult to control. Let's talk about that. It's those discussions that lead people to interesting decisions. Sometimes they're decisions to leave a very high paying job for a lower paying job, but then the depression goes away or the substance use goes away. Sometimes it's a decision to strive for more that leads a person, ultimately to achieve external measures of success.

But we don't know what that is. We don't know what that is. But if we start thinking about it and talking about it, we also go back to the basics of how are you taking care of your body. It's going to be very difficult to feel good if one is not taking care of the basics of their physical function. We get down to the first principles, physical health, the things that contribute to lifespan, health span, cognitive health, and emotional health. But we have to go back to the first principles of who are you? Let's talk about your story. Because that understanding is what leads to the next decisions. The next decisions are not obvious from where we stand now.

How positive in terms of its predictive value would the following be? And again, I'm still thinking through this as almost a self-audit tool. If a person ostensibly recognizes that they are not taking care of their physical health, they're If you're drinking too much, smoking, using substances in an unhealthy way, eating too much, not exercising, all of these things. If a person can recognize objectively that those things are true, and that's a generally pretty easy thing to recognize, What is the PPV, the positive predictive value of that sign that says there is something unhealthy going on in me emotionally?

Recognizing the sign?

If those signs are present, the physical not doing the things to make yourself the best version of yourself physically, let's assume that that's easy to recognize. How likely is it to then be predictive of the fact that you're emotionally unhealthy?

Oh, very, very high. Very, very high predictive value. Because think about what's the link between the two? It doesn't feel good to get up every day and not feel good. It doesn't feel good to know that one is unhealthy and energy levels are low, or it doesn't feel good to look at oneself in the mirror and say, I could, would, should be healthy. Healthy, or to not be able to keep up with one's kids or whatever it is that goes on inside of us that makes us know that. If that's going on, something isn't aligned well within us. What is the reason for that? I have to work to do this, this, and this, so I don't have time to take care of myself, or I've got to be in this job I hate. I'm so stressed. We have all these reasons, but there aren't good reasons. This is what we have. Our bodies and our minds are what we have. So the idea that we can just push that aside and not pay attention to it can't be right. It cannot be right to not pay enough care and attention to everything that we have as we move forward.

The key is the curiosity to link the two. So there's a high positive predictive value that there is something emotionally then out of balance, if we want to look at it that way, or something in the mental health realm, whatever it may be. But whether or not good comes of that is the link of curiosity.

It's amazing, Paul, because that's such a common phenotype. For all of us, I include myself in this category. There are absolutely things that I do. For me, it's clearly overindulging in food often. Even when I'm saying to myself, Peter, you don't need to be eating this extra helping of dessert or whatever, how do I think about that in a way to not overanalyze this or overinterpret it? How do you decide if my over eating is actually a canary in the coal mine that says, Hey, there's something going on inside of you emotionally. And my wife and I will talk about this all the time. She'll be like, You are really emotionally eating right now. And I think we talk about that a lot. I think we understand what that means. She's like, You're so stressed out. Get out of the freaking pantry. You've been walking back in here every 20 minutes, and your elbow deep in the Pringles. What's going on? Is there pathology there? Is that sometimes an okay coping strategy? I want to be careful not to demonize everything, but at the same time, I want to be able to use this as signs, because again, I'm coming back to this idea of, man, when it comes to this domain of health, we don't have biomarkers, we don't have scans that give us answers, blood tests, tests that you can do with objective measurements.

I'm searching for other ways to gain an insight into how do I at least start asking questions to get myself help.

In this scenario you gave where It's a subject of conversation Hey, you're doing that. You're stressed. You're emotionally eating. Then we know there's something there. But a lot of times, a place to start is, are we overmanaging ourselves? Every now and then, a little bit of indulgence is okay. Let's make sure that it's not that that we're criticizing, that we're actually recognizing something that we don't need a biomarker for. Look, when I am very stressed, I am eating in ways I don't want to be. It sooms me a little bit at the moment Then I feel worse about it, and I got to go do something to make up for it. That's not good. That is face validity. That's just very clearly not good. Then what we can do and often do is just simply perpetuate that, to recognize that, and it goes no further. Then we continue to do it as opposed to saying, Whoa, this is the place for curiosity. That's interesting. What is different about the feeling inside of you if you eat because you're hungry or you eat because you're Can you recognize that difference? Maybe you can. If you're paying attention to it, a lot of people can.

If not, what's the context around? You can have an idea of what's going on inside of you, and then it fits into this human thing that we do, which is short term gratification at the expense of something that in the long term is negative. This is why when we were back in medical school, people were not very interested in studying addiction. The thought was that addiction was separate from other mental health things. It was people who were doing something they shouldn't and then weren't able to stop. It was a very, I thought, denigrating and disinterested approach. It is so different now because what I think the field has come to recognize is that these addiction mechanisms is going on in all of us all the time. The short term soothing of a little bit of food that isn't healthy for you at the expense of you feeling badly about yourself in the longer term is part of that same cycle. It's the same brain machinery that is getting harnessed so that we over prioritize the short term at the expense of the long term while looking away from the fact that we are doing that.

If we become curious, why is it? What crests inside of you that you, a person who's very good at looking at the long term and foregoing immediate gratification and all of that, would say, I'm going to sue this right now with food. If we look at that, the thought would be, we've got to be able to do something about that. You've done much harder things than to realize, Oh, there's an emotion inside of me. Wait, let me go look at what is that? What is that emotion? Where is it coming from? Maybe you can't stop the emotion in the moment, but it might tell you, Hey, this thing in my life should be a little bit different. Or it might say, I crest like this with a relative frequency. Is this okay? Can I take care of myself? Because sometimes it's harder answers, too, that the answer might be, Well, a person should do less. The answer isn't, Keep doing everything that you're doing and don't have these emotions that crest in certain ways. The answer might be, Why are you doing all the things that you're doing? Again, I'm not saying this is the case for you, but we need to all look at this.

What is going on inside of me that something is cresting and all of a sudden I prioritize the short term? And I don't look at that. This can be the beginning of 30 sessions of weekly therapy with a person of talking about this paradigm within us of, how are we doing this for all sorts of things in life? What might we be rationalizing about our choices, personal and professional. How are we taking care of ourselves? What's the climate inside of us? Because when a person seems to be taking care of themselves from the outside, and maybe is, you can see from the outside, but they're so frustrated on the inside, or they're so afraid need, or they're so overly managing themselves to make up for something, then we don't necessarily see that that keeps them healthy. There may be a higher inflammatory state that increases risk of cardiovascular disease, for example, or of autoimmune phenomena. We know this happens. So we have to be curious about ourselves. And it is amazing what we hide from ourselves. We go through life hiding so much of what is going on inside of us from ourselves in the service of maintaining some direction, we've decided was important.

I've got to go do that. I've got to go achieve that. Then we put these blinders on ourselves and we don't look, does this make sense for me? Am I being the best person that I can be? What's the whole set of priorities in my life? Personal and professional self-care about other people that you care about, about achievement. Am I balancing all of this right? It's remarkable how little we inquire of ourselves about our own unhappiness or markers of our own unhappiness, even the excessive emotional eating. It may not be the determinant of absolute misery for a person, but there's something going on there that's not happy, that's not in alignment with oneself.

I think there's continuum from what we just talked about, which is people that are from the outside. It's obvious that they're not taking care of themselves. And again, the patterns here are many. It could be just a straight up across the board. I don't sleep well. I don't exercise. I don't eat well. I drink too excess. And in those situations, I guess it becomes pretty obvious to someone on the outside, Hey, there's something going on here that you're acting in a manner that is harmful to yourself. We should explore why. Then you have the intermittent example I talk about using myself as an example of, Hey, for the most part, you're taking reasonable care of yourself. But then you really have these breakout moments where you're soothing something, some stress with a maladaptive behavior. And then, of course, you have probably where I think I used to live, and I think there are a lot of people, though not nearly as many, who also live here, which is the over-management, which is you're going to be perfect, you're going to be By any objective measure, you're going to have it perfectly dialed in with respect to your health.

You're going to eat like a robot, exercise like a robot, sleep like a robot, etc. That's probably a harder one to get people to look inside and see, isn't it? And if you were talking to somebody like that, and somebody watching us who might be that person, how would you help them come to realize that while on the surface, that looks really good, and it looks like they're doing everything so well that they clearly must be doing this from a place of health, how would you at least challenge their thinking on that?

One route of approach is the old Freudian way of seeing this, which is no less valid just because it's old. And the old Freudian's They didn't get everything right, but boy, they really got some things right. And they thought of this as what they thought of as living in the ego. It wasn't the modern idea of ego. It's like that's a person at their best, at their most self-aware. And it's not easy to live in the ego. We have to think about ourselves in order to be self-aware, in order to be aware that we're not aware of everything. It's this idea that as best I can, I understand myself and what's going on inside of me and what my hopes and fears are and what I want and what I have achieved and what I'm afraid of. It's all within us. And the idea is from there, then we can healthily control our lives. But we're keeping two other aspects of ourselves in balance. And what they thought of as the id was the desire for immediate gratification. I feel bad now. Where's the food? There's that part of us. I want what I want, and I want it now.

There's that part of us on one side, and the other side is what they call the superego, the part that manages us, that says, You want what you want when you want now, but that's not okay. Keep yourself in check. And there are these parts of us that manage us and that want indulgence, and that it's us, the whole us in the middle, that has to recognize all that and keep it all in balance. And what we see is that part they call the superego, the Self management often gets very, in the circumstances you're talking about, gains supremacy over the others, and that's not good. That's how we internalize the persecutor. There have been times, it's a parallel to this, but this is a true story. Where someone who I haven't seen before who is in my office and I'm getting to know them, and they're telling me about being really persecuted by someone who says, You can't do anything, and you're not worth anything. They're describing and talking about all of this, and I'm thinking, Okay, Okay, let's think about where is this person living? How can we get them out of there? Then I learn that other person has been dead for seven years.

But the person took into themselves the persecutor, the you're not good enough. Now, that can come from outside of us. That's very striking when it comes from outside of us, and it does often. It's not striking and rare, it's striking and relatively frequent. It can also come inside of us. Now, there's probably some external modeling, but it can come inside of us where I decide the way I'm going to be good enough is I'm going to berate myself and torment myself until I'm perfect. Perfect isn't just the enemy of good enough. Perfect is really the enemy of everything that's not misery. No one is perfect. Nothing is perfect. When we're over-managing ourselves, that's what we're telling ourselves. This super ego part of us, if we want to call it that, is always looking at us. What are you doing wrong? What's not right? What's not good enough? And that becomes a very harsh critical voice. And often we don't know that that's inside of us. I tell the story at times of a person who was very underachieving, given this person's level of intelligence and other things that they had done. They were so below in role performance, what one might have expected.

I couldn't understand. I'm going to start asking questions, and I'm trying to understand. Then I realized this person loved music. I said, What music are you listening to? I'd learned the person was taking these long drives to go to some awful job that they didn't have to have, and they weren't listening to music in the car. We're not listening to me. Now we have a clue why is this. This person loves music as a music aficionado because without the music, the person could, uninhibited on all that long drive to the job and all the drive back, tell them what garbage they were, what a loser they were. This was going on the whole time. In fact, the person was going to a farther away job than they could have gone to to have more time to criticize and berate themselves. It's an extreme circumstance, but it's not that uncommon that we see things like this. That person needed to stop that in order to increase role performance, which is vastly higher than it was before. It's remarkably different than it was before. But the search for perfectionism through self-criticism, because when you explore that, the person wasn't aware that they were being sadistic to themselves.

No one says that when you say, What's really going on there? That actually I'm being sadistic to myself. This is what I need to do. This is how I keep myself moving forward. This is how I get myself going to any job. No, it's not. No, this is how you're keeping yourself down. But those voices inside of us are very powerful. And yes, I've given a couple really strong examples, but they're not outlying examples where, oh, they're so different from what goes on in us. I think they're examples to elucidate what very often is going on inside of us, where we are trying to manage ourselves, whether we're being perfectionist about it or we are afraid, or we are ashamed in ways that are very, very harmful to us. Because I think that self-taught destroys motivation, destroys confidence, increases levels of inflammatory markers, increases risk of illness. There's so much bad that comes of that. But that's inside of a lot of us. That is inside.

If a person stops now and think-Is this person aware of it?

Yeah, if they stop and think, is that inside of you? It's remarkable how many people stop and think. Yeah, I'm in the shower in the morning telling myself, Of all the things you better not mess up today, or, What did you do wrong yesterday? There's so much of it inside of us.

Did you have to prime this particular individual to get them to recognize consciously what they were doing?

Oh, sure, because we had been talking for a while, so clearly the person wasn't aware of it. We had to, through a process of inquiry, we had to stumble across something that didn't make sense. When I learned, this person loves music, then I just got that in my head. This is what this person They listen to music when they're home, and they have this really long drive. And then I learned they're not listening to music. Then I become curious about that. Now, maybe there was another reason. They liked looking out the window. I don't know. But it's like, Wait, let's inquire there. So then when I point that out, you're taking a longer drive and not doing something you enjoy in order to punish yourself. Well, now we have curiosity about that. How can you not be curious about that if someone you've gone to for help is drawing your attention to that? And that's often how we start changing things, even within myself and in my own therapy, of realizing there's such a negative critical voice all the time. And it wasn't needed to help me move forward with life. At some point in time, trying to control things around me and feeling afraid of not being successful or not being good enough leads me to start managing myself pretty closely.

But then I stopped managing myself where when I was in high school, I could do three sports over the course of the year and still maintain academics. That was good to learn how to do that and balance fun and work. But then it gets to be too much of a good thing. And now I'm going to manage myself by being so critical and telling myself all the things could go wrong and knowing how I'll feel and making damn sure that nothing is any less than perfect, which of course it is. Now I feel worse about myself. That in me, like in many people, was why I could look successful from the outside, but for a long, long time was really not happy and depressed and ashamed of things and feeling in ways I had to then through my own work, get out of me. It's experiences like this that helped me have insights, I think. One doesn't need to go through something to know that others are. But having been through a lot of that, I've learned what you see on the outside. Does It doesn't tell you at all what's going on on the inside.

Seeing a beautiful home doesn't tell you what's going on on the inside of it. Who are the people? How are they behaving? Are they healthy? It's not that it's irrelevant. There's a beautiful home on the outside, but it's also not irrelevant if, let's say, there is a home that doesn't look so good on the outside. There could be so much beauty inside of it and so much happiness inside of it. And we know those things are true. You and I have both been around life enough to know that those things are true. So let's bring that to the forefront. If we know those things are true, let's look inside of us with the same curiosity and not having to hide from ourselves what we might find there.

I wrote a little bit about this in the book, about the discovery of the inner voice. And in my case, it was so startled startling. I say startling not because I had an inner monolog, which I suppose many of us do, but in terms of how aggressive and the Bobby Knight voice. But it was remarkable to me. I just had a breakthrough one day at PCS where all of that came out, that that's what was actually happening. It's a little sad to me to realize that whatever 47 years of my life went by, probably 45 of them with that voice, and yet no recognition of it. And why that is frightening to me is it tells me there have to be a lot of other people out there with potentially as awful a voice in their head. They might be listening to us now thinking, Yeah, that would be awful. And yet they have it and they don't recognize it.

Right. If your experience of it normalizes it, and also if you have an emotional investment on some level that this voice is causing you to behave and achieve in ways that let you feel good enough about yourself, and even then you don't feel good enough about yourself, so you're really afraid of feeling worse, then it gains almost a buy. We don't go and look at that. It just gets a pass. That happens all the time. It's so automatic within us. Just as there are people who, say, around 20 years of age, can have schizophrenia that they didn't have before, and they're hearing voices inside of them, and it's only till years later that they realize that's not normal, because they had an experience of now hearing voices inside of them, and they don't know that that's not normal. Even something we would think of that's so different to what most people are experiencing. But it's not different from what you're experiencing if you're experiencing it, and it's come about in a way that didn't have a marker that told us that it was not healthy. There's a common theme to what we're talking about, which is introspection, curiosity of like, wow, there could be things going on inside of me that are wildly unhelpful to the things I'm trying to achieve, like better health span and lifespan or better emotional health.

There wildly counterproductive, and they're just going on on the surface. They're hiding. There they are, waving a flag, and I'm not paying any attention to it. So it is curiosity about ourselves. How do I work? What is going on inside of me? That makes all the difference? And when we start thinking about that, we become aware of it, that's when we can change. Because you describe feeling all this all at once. But that's how change happens in people.

There's a great Hemingway quote, which I'm paraphrasing incorrectly, which was, Change happens incredibly slowly and then very quickly.

Right. If you think about quantum leaps, or you and I both mathematics people, like asymptotic functions, what we're getting at is discontinuity. I think this is true on all levels, down from quantum physics through to astrophysics, where you see that we are only here because we are in these eddy pools of counterentropy, where instead of everything dividing and dispersing, forcing like it does in the vast majority of the universe. There are these places where, Oh, certain forces go the other way. Now, there's not things coming apart, but coming together. Whether we're looking at the biggest levels or we're looking at the smallest levels, the way that things work inside of us is that there are processes of understanding and change that are rare or infrequent, but that we can bring to the surface by looking in the right place. If you look all over the universe, most of what you see is no life. But if you look in the right places where those forces of coming together are more than coming apart, then you see, Oh, there's something that's happening there. The same way inside of us, if we're looking where things are happening, then we can gain understandings that happen very, very quickly, just as in mathematical functions or quantum leaps, these things are discontinuous.

When you develop, I think this will be my thought about that, when you have a curiosity about yourself that leads you to now do something where you're thinking about yourself and you're thinking about yourself with the help of other people outside of you, and you've engendered this across time, and now you go do something that's intensive, then all of a sudden, something becomes clear to you. You see, Oh, I'm now interested in this. Now you start to do all the things that you do when you're interested in things like, Why is this here? How did this develop? How is this serving me? How might this be working against me? Now you can change. Now you can change that when before you couldn't change it. Now, yes, change happens slowly. It's slow, slow, slow, slow, but then it happens fast. You do a lot of work on yourself to get to that point where the change can happen, which I think is true. Again, these are human, and maybe these are principles of existence. Same with physical health. This person works out and works out, and they don't immediately notice linear change. You have to have faith that the work you're doing is going to get you there.

Lo and behold, it does. And that's how these really big things inside of us. What am I saying to myself? Is there a running narrative inside of myself? Is someone else's voice inside of me? These happen to us, and it's amazing that we often just don't know it. Then isn't it more likely that we're going to choose the short term soothing in the light of that? Then, of course, just get some soothing on board, whether it's Pringles or it's a drug or it's whatever it may be. We're more likely to choose short term soothing because we're afraid and we're out control and we're berating ourselves. It's like, whoa, whoa. Let's just bring some peace and understanding to this equation, and then things will change for the better, even if you have to change things for the better. Make change.

Yeah. I'll tell you a funny story that happened today These things occur on a daily basis. So I get a daily reminder of this, and it amazes me. So I was shaving today, and then I went to grab a brand new bottle of aftershave. So this Nivea big glass bottle of aftershave. Same thing I've been using for 25 years. And this is the first time this has ever happened, Paul. I went to grab the bottle and I opened it. And as I was dumping it in my hand, maybe because it's so cold today, it was harder to get out. And somehow the bottle dropped, and it landed on the floor, and it's a glass bottle, and it shattered. So now you've got glass and aftershave on the floor. And in moments like that, I'm always now paying attention to... Because If there's no one around for me to talk to. I'm not going to yell out loud or anything. And the only thought I had was, Oh, let's make sure you don't step on the glass. Looks like there's no glass over there, so let's just walk over There we go. Do you have another bottle?

Because you're not going to want to reach down on the floor and mop some of that up because there's probably glass in it. Okay, found another bottle. Way we go. And I remember thinking a minute later, Wow, what a different conversation that would have been five years ago. I mean, that would have been a three-minute internal lashing of you incompetent, non-attentive piece of shit.

What?

How could you possibly drop that? But again, the thing that I gravitate towards is the ability to start paying attention, to just listen to that voice. And again, I've talked a lot about the exercise that I used to do that, which was suggested by Katie and by another therapist at PCS, which was the recording. For anyone who has not heard that, I think it is worth, even if one person listening to this has not heard this story, I think it's worth repeating, which is I was instructed as I was leaving PCS yes, to take my phone out every time I made a mistake or fell short by whatever metric, and to speak out loud, audibly and record the way I would speak to my best friend if he had made the same mistake. So if my best friend had just dropped the aftershave, I wouldn't yell at him and call him a piece of shit. I would say, Are you okay? Those are really small pieces of glass there. Let's not step on them. And while that now is a very easy thing to do, it took months of recording those. I still have a number of these recordings, believe it or not, which I would then forward to Katie each time.

It's confusing to note how strained they were at the beginning as I had to learn a new language.

The, well, I hope you're okay.

It's okay. Now, of course, it's very natural. So again, I highlight that to say, That was a technique that worked for me. Incredibly powerful. But most of all, I think the moral of that story is malleable. When this exercise was suggested to me, I did it because I was at rock bottom. And when you're in rock bottom, you don't really have a lot negotiating power. You can't say, that's a dumb idea, because it's like, well, how's the current one working out for you? I don't think I actually expected it to work. And I thought, if this is ever going to work, it's going to take 40 more years, because that's how much we're overwriting. Why do you think it took, I mean, I'm not exaggerating, Paul. It took about three months to totally change. How could it have happened so fast?

I think three months to totally change, but that's three months of work. It's that same theory that That matter is not evenly distributed, change has not happened in a linear way. Okay, it's only three months, but you had to run countercurrent to patterns of neurotransmission that were inside of you for years and years and years and years. This is another, I think, big problem with modern mental health is it's packaged to suit insurance paradigms, and that's not serving the people it's supposed to serve. The idea that whatever has gone on, there's 10 sessions of therapy authorized, This has to be gained in a short period of time. Let's take an inventory of symptoms and let's throw a medicine at you so now your symptom is a little bit better without ever knowing what's undergirding it. There are things that take time. When we establish patterns of neurotransmission, it takes time to unestablish them. The example I often give is if you and I picked a random word and we said it a thousand times, we're going to be saying it later today. If we say it 5,000 times, we're each going to be saying it tomorrow and over the weekend.

Why? If we know that it's just a silly experiment, why would it stay with us? Because we said it. The brain's mechanisms are designed to hold on to it because we said it a lot of times. That's how it goes. The same is true, of course, with what we're thinking. We're just thinking what we think we put into words, it's the same. It's thought. It's neuronal connections that don't want to go away because this is how we've developed. We've developed to remember things. We've developed to not forget things that are important. The brain says, You said that word I'm not just going to forget it because you said it. It's the evolutionary mechanisms. So that's been in you for a long, long, long, long, long time. And when you start trying to say something nice, tell me if it's true, there's got to be a fear in you. They're like, Everything is going to fall apart. Here you're doing this wild reckless thing, right?

Which is going to take your edge away. Because the Bobby Knight produces great results.

Next thing you know, you're going to be lazy and slovenly and not care about anything.

You're not going to care when you make mistakes.

But think about on one hand, how outrageous that is, the thought that you could possibly be like, a million miles from that. But it's not outrageous to the emotional part of your brain that didn't want to stop it. So it takes bravery to stop it. You have to take a chance. And that part of you that says, you're going to fall apart and you think you feel like a piece of shit. Now, wait till you stop doing this. You have to say, no, I hear them and I'm doing something different. It's a leap of faith in myself and in what I've thought about and learned about myself. Then you can go and do it and you start running counter to those neuronal connections, and then it changes. But it takes time, it takes effort, it takes bravery, it takes faith in self. So when you say, Okay, it only took two months, but you worked really, really, really hard at it.

It was actually probably four.Call it three to four.

Three to four, okay. So then we're talking about like 100 days or so, really, really running against those patterns and making new patterns. And then it feels different. As someone who has known you over a quarter century and loves you, and also is trained as a psychiatrist and was here when you came out with the remains of the bottle, it was not lost on me that you're like, Oh, I hadn't done it before, and I dropped this bottle. There was no edge in you, and it was not lost on me that, Wow, that's not how that would have been before. Then I think, Right, you're happier, you're healthier. If we think about health span and lifespan, coming from the place that I come from, from the mental health side of things, and really is it psychiatry? I think it's active brain function, emotional states within us. This is how I come at health span and lifespan. I think this is good for you. Then I know you're healthier inside, even without... It's great that biomarkers and all that. But there's not a biomarker for that. But I could see and noted, not that long ago, that change in you.

And I knew you are happier, and this is healthy for you.

Now, I don't want to make it all rosy, but using myself as an example and to talk about an area where it's still very difficult, and I've maybe only had a 50 % improvement, which, again, in magnitude is huge. But given where I was starting, there's still a long way to go. So it's like saying, if a person loses 50 pounds, are they necessarily healthy? It depends. If they went from 220 to 170, they almost assuredly are. If they went from 400 to 350, they probably still have work to go. I'm probably the 400 to 350 guy in this area, which is just general outburst of anger at a situation that almost assuredly warrants anger. So to be clear, it's something happens that warrants anger, but the response is disproportionate to it, and it's counterproductive. So the exercise here This is an exercise suggested by Andy White, who, of course, you very graciously introduced me to. He said this is an exercise that he does with patients he's working with who are trying to quit smoking. So the exercise is about separating, creating a discontinuity between urge and behavior. So he says, look, and I'm probably bastardizing this a little bit, but let's just say for the next month, you come in here and you're smoking two packs a day.

For the next month, I'm not necessarily going to reduce the number of cigarettes you smoke. But what I will do is separate the urge from the behavior. Every time you have the urge to smoke, I want you to pull out your phone and set an alarm for 40 minutes. Don't smoke now, but when the alarm goes off, go smoke. Going to separate that so you're not just feeding an urge every time it comes up. You're going to go smoke, and sometimes you might not actually even feel like going for a smoke. And so what the exercise was for me was, the next time something happens, something stimulates a response in you that is going to be an outburst of anger. And that could be you're going to fire off a really nasty email to somebody, or you're going to call somebody and tear them apart. Pause, set an alarm for an hour, and And then come back and respond in an hour. And again, that's much easier to do over email than it is to do sometimes on an interpersonal level. But not surprisingly, when I'm able to do this, and to be clear, I'm probably only batting 500, meaning there's a lot of times I'm failing to do this, and I'm just reacting to situations in ways that I almost always regret, as opposed to responding to situations.

But when I'm able to do the urge right now is to react, stop, come back, respond, I mean, it's always better. So my question for you here is, why does this appear to be a harder exercise? And would you modify the exercise in any way to produce even greater efficacy, or am I just being impatient? This one might take years as opposed to months.

Anger is very, very powerful, and anger can propel us forward. I always think of sprinters coming out of the blocks, and if they come out too fast, then they don't have control, and they're just flying headlong until they fly face first. That can happen because they're propelled out. They propelled themselves out too strongly. Anger does that inside of us. There's this cascade from what technically is affect to feeling to emotion. It's worth pointing out the difference that affect is aroused in us, meaning it's created in us without choice. When we have high levels of emotional response, some of it is nature, some of it is nurture, it's cultivated over the years, and then these pathways are very strong. So something is negative, and there's a high level of aroused negative affect, anger in this case. And then that propels forward. So when it comes in us, we don't even know. Affect is aroused in us. We're not even aware of it yet. It's just a split second. But now when we're aware of it, it has a whole head esteem, and it runs through feeling when we relate it to self and emotion when we relate it to others.

So I am angry. I am an idiot. Man, we went from a lot of aroused anger right through affect to me, and now I'm mad at myself. Or if the target is someone else or something else that has happened to us, then we run right through us. There's a lot of negative affect of anger raised. And of course, this is what happens to me. We burst right through us and now we're like, And it's your fault, or it's God's fault, or it's fate, or nothing ever happens right, or I'm cursed. And now we relate it to the world around us. I view this as the equivalent of the sprinter being 25 meters from the start of the blocks, sprawled face first on the track. It's not good. It leads us to unhealthy places. Andy White and Katie Powell, they're fabulous therapists. So what they're doing is they're saying, Hey, we've got to put a hand between the dominoes. Dominoes are going. This is running ahead. We got to stop, slow that sprinter down, coming out of the blocks so that that person has healthy control over the movement of their body. They're not just flying ahead.

What they're doing there is they're trying to slow that down and say, Our affect does not have to run right to feeling when we're related to self and run right to emotion when we're related to other. Let's slow that down. This is a lot of work that we do. We do intensive programs with people where people come to us and they spend a week with us or two weeks with us. We do a lot of this work now. A lot of the time, the work is around things like this. It's around people like, I want to understand myself better. I know that this, whatever this may be, is not good. I want things to change. A lot of what we're doing in that time are these strategies, like you're saying, because they work and we know why they work. But also there's another aspect of this, and we do this also in the intensive work that we do. This is the part I'm most interested in, which is in the understanding of it. To me, it then becomes interesting that you become very angry. Let's say for me, if I become very angry about something like, Oh, the flight is delayed, or I rushed to get to the airport and the flight is delayed, and I didn't get the text I was supposed to get, whatever it may be that I become angry.

I'm very curious as, Why am I angry? I say, Oh, my flights are always delayed. None of this is true, actually. I'm a very fortunate person. I see myself as a very fortunate person. I don't feel that I'm cursed or that bad things only happen to me or that people have it out for me. But in the moment when something triggers anger, that's not how I feel. So the strategies help you slow down. But what are you slowing down to?

So the slowing down step is necessary but not sufficient for the real insight.

Right. It could be sufficient if sometimes just slowing down, it dissipates the energy. But we want more than that. I mean, that's something. How about combining it with understanding, which Which brings me back to what I believe works for everyone. This is a human thing, and it crosses cultures, race, religion, socioeconomic status. We are humans, and we have these drives within us. There's an assertion drive to be able to have some healthy control in the world. There's a pleasure drive to feel at least no privation and feel safety. Then also to have good things. If we look, we have these drives, and there is also a generative drive in us. Are we honoring the generative drive? Are we in balance? Then what comes of that, if we are doing that, is a sense of gratitude and humility. I think my idea of what's going on inside of you when you're able to stop is that you're able in taking stock of self and being reflective to feel, whether you see and put words to it. You may or you may not, but there's a knowing inside of you that actually your assertion drive is like, you're doing well with it.

You're putting yourself out there in the world, and I'll take stock of myself. I'm not unhappy with how I'm trying to be in the world. I do take some pleasure and satisfaction in what I do, and I'm able to provide for people, and I feel a sense of wholeness and safety. Because of that, I can feel good about myself, and I'm learning and curious. I'm really like, Wait a second. Your life is great. There's nothing wrong with your life. I feel a sense of gratitude because so much of that is blessing. Also the sense of humility we have when we recognize our own work and effort, and we recognize our own responsibility for where we are. But we also recognize that it's also a blessing to be able to bring ourselves to bear in that way. This is why people say, I got an award and it was so humbling. You say, Why would that be? It's because the person recognized, Yeah, I got that award. I did those things and I worked hard. Also, isn't it wonderful for people around us to acknowledge me? Isn't it wonderful? I've got it in myself to do.

Gosh, I'm fortunate enough that I could bring myself to bear so I can both own it and also feel a sense of the beyond me that, Oh, my God, I'm so fortunate to be in a place where I can own that I worked hard and got something. I think this pervades people when those other drives are in balance. If we go back to what we started at the very beginning, how do people have health span that is a wonderful health span to be have. It's combined with lifespan and cognitive health and emotional health. The drives inside of people are in balance, and you've got to look in yourself in order to get them in balance. We've been talking about that, too. Then when they're in balance, you orient yourself to that balance, and you live much more in an appropriate and active sense of gratitude and humility, and How do you feel that when things are difficult. I think that the work that you've done let you feel a sense of humility. You are not supposed to be perfect despite all that you have achieved. Isn't it wonderful? All the great things in life. Then the glass bottle breaks and you're like, That's it.

That's why when I go to the airport later today, if the flight's delayed and I'm going to sleep in the airport or whatever it may be, that's not going to feel great. But I am not going to get down on myself or anything else around me, whether it's God or fate or people. It's not right, and it's not good for me either. That's another reason we don't do it. That's why once you start doing it, you make progress. That's why, say, you're 50% of the way there. That's a huge achievement. What does it tell me? The next 50% can't be as difficult as the first, right? So you're going to get there.

What percentage of people do you think, or how often do you encounter this, maybe as an easier question, of an individual who feels frustrated or upset at themselves for the following paradox, which is on the one hand, intellectually, they recognize how lucky we are, any person. We talked about this a little bit over dinner last night. I'm reading this book about the impacts of the dust bowl and the depression. This is 90 years ago, and the people living in the middle part of the United States were subjected to conditions that most of us couldn't survive. I mean, the abject horror of what it meant to live in the depression, in the dust bowl. And the book I'm reading is called The Worst Hard Time, which is amazing. And so you think about that and you think, God, that was only 90 years ago. What's the luck that allowed me to be born now instead of then? Had I been born 100 years earlier, I'd be dead. I would have died an awful death in that situation. So I know that in my head. And then something happens that upsets me. And again, it almost doesn't matter what it is because you think it pales in comparison to what it would have been like to have born just 100 years ago.

And then that creates tension internally because you think, why can't you just be grateful Let's use the airport example, right? Why can't you just be grateful that you can at least get on a plane? It's a miracle that we can do this thing. And yes, so what if it's four hours late? But then you still feel like, but I'm still really upset about it. How often is a person coming to you where that's the source of the tension, the difference between the intellectual understanding of what should be gratitude and the emotional feeling that is incongruent with it?

A lot. If I could comment a little on what you said. I think that there's a fallacy there or a problem. I don't know what word to put to it, but something is not real or healthy in the framing. I do not believe that you would have just died if you were in the Great Depression, in the great dust bowl. I also don't know that you wouldn't have been happier.

I mean, I don't know that.Yeah. It speaks to what we said earlier.

I mean, maybe you would have barely eat out enough food and got some shelter and kept your family going and dirt poor, but everyone stays alive. Or maybe not everyone stays alive, but you keep alive who you can keep alive, and you You have a sense of wholeness and goodness in yourself despite the privation. When we set up, Oh, we should feel grateful because, then you set up a scenario where you can't win because anything you feel bad about, you should feel ashamed about feeling bad about because it's not the great depression and the great dust bowl, so what are you complaining about? Then I think you've inadvertently set up a situation where the odds are against you. I'll think this sometimes where up until a couple of generations ago, probably everyone in in my family from all sides, extending back generations, was a shepherd. So you could look and say, Wow, Hilton, look how fortunate I am. Look at the opportunities I have and the places that I've gone. And I can get into that way of seeing of like, Oh, my gosh, this is so amazing. But then I'm not giving myself room to say, Maybe I would have been happier being a shepherd.

I don't know. Maybe if you and I were shepherds next to one another, we'd help each other, others flock out. We have a little bit more sheep. Our families are doing okay. We have a lot of leisure time. We think and talk. Who knows? You are you. You are not someone else. And you are also you now. So a lot of people come with what you said. And what I try and do with all of them is to say, This is not a framing that we massage. I think it's a framing that we just throw out. I know nothing about you by knowing your reflections on what you think it might be like if you were in the Great Depression. What I know about you, I know from now. This is when you live your life now. And you know what? You're entitled to be angry and frustrated about things sometimes. Now, do you want to modulate that and keep it inside and not let it run out of the starting box? Yes. You're entitled to feel bad about things or annoyed about things at times. This is how this goes. Just because we are not suffering, we can compare ourselves to people all over the world who are suffering.

We're living our lives. If we live them within ourselves and we are the marker of comparison. How am I taking care of myself now? How am I exercising the drives within me now? How am I serving the generative drive within me? That's between you and you right now. When we bring people back to that, that's when things can really, really, really start to shift because you then maybe stop doing something that is like going to do something, and immediately you set the odds against yourself by having this comparison. I'm not in the war. I'm not in the Ukraine, or I'm not in Israel. I know that, but that doesn't mean that you can't suffer now. It's true, true, and unrelated. The other aspect, as I said, don't be an isometric exercise. You might do them. If this is you, don't push against yourself. That's often what we're doing. If I want to go this way, can I glide my hands this way? Very often what we do is we have 10 units of resistance and 11 of force. We're doing that within ourselves instead of simplifying. The rule of all good mental health, which I believe undergirds health span, lifespan, is simplicity.

It doesn't mean it's simple to get to, but it is simplicity. It's really, really complicated to start comparing you to the theoretical you 90 years ago. I start getting very, very confused. But we all do when we do that. And again, I'm not being clear. I do this to myself, too. When I just stop and think, Look, there's me. I'm here now. I know my own history pretty well. I am capable of introspecting. Let me stop and think, What's going on inside of me? Am I making a decision? Am I upset with myself or someone else? I've got to be able to understand this well enough to simplify it. And if I'm going to beat up on myself and flog myself to get myself somewhere I want to go, that's not how I'm choosing to do it. It's just not good. And is that why things seem to maybe take more energy out of me than they should? These are things that you and I both tried to work with over time. Then now am I more easily frustrated? I'm not getting enough sleep or I'm not sleeping as well, so now I feel a little bit fatigued.

It's harder to take care of myself. There's more inflammatory markers. My Why it doesn't feel as good? So now I'm even more frustrated with myself. Like, what is going on here? We can stop and take stock of things and decide a path forward where we are not working against ourselves and we simplify down to what the real truths are, which I'm not saying that's easy. It takes work and it takes reflection. We've got to run counter to some of these established neuronal pathways. But isn't that a lot easier and a lot more likely to be effective if you're living in the here and now with yourself, knowing what you know about yourself as you make decisions, whether it's what am I going to say to myself inside of my head? What am I going to say to someone else? What am I going to do? Now we're intentional. Now, in that Freudian way, we're living in the ego, in that sense of the ego being the whole Am I most self-aware? I'm aware. I don't want the super ego telling me, I actually feel bad about any frustration in me because I'm not a shepherd.

I'm like, I'm not having any of that. It doesn't help me. It makes things worse. It's the opposite of simple. We can reject having ourselves be out of balance. Just like our drives need to be in balance because then the generative drive is what makes you wake up with a glimmer in your eye. But we have to be healthy in mind and body. These other drives, the assertion and the pleasure, have to serve it the same way we have to be balanced inside of us. We need some gratification. We also need some self-control. How about we have as clear a lens as we can sitting in the middle of it all? Another way, I'm using a lot of analogies, but I don't want fun house mirrors around me when I'm trying to see what's going on. I want clarity around me. A lot of times, what we don't realize is we create funhouse mirrors around us, and then we get angry with ourselves that we don't understand, or that we walk in the wrong direction, or that we run into something.

In this analogy, is the funhouse mirror the construct, the mental construct that adds confusion, such as the example I just gave?

Yeah, I think that. A funhouse mirror comes into the room when you start comparing you now to the theoretical you during the Great Depression. Now, there's a funhouse mirror. It's a funhouse mirror when I'm mad at myself because something wasn't good enough, and I realized that the standard I'm using is actually perfect. Bring another mirror in if I start speaking to myself through the lens of someone who is so critical to myself. These are all the distractions away from clarity, and it is so easy. No one else brings the fun house mirrors in. No one catapults ourselves out of the block so that we fall headlong. It is we who do this to ourselves, and we don't have to do this. Think about what humans do. We create so much, and we destroy so much. Isn't that true? The destruction in the world around us, how long it takes even to create one building that gets destroyed, let alone the vast swaths of the Earth that we then destroy and the harm that we do to people. So just as in the universe around us, there's a lot more force towards entropy than there is to things coming together.

That's why these small places where life could be here. This is true in our lives here on Earth. It is so much easier to destroy than to create. If we stop working against ourselves as humanity, we're trying to move forward and create. Is it 11 units forward, 10 back? Well, maybe we'll get that wrong. It'll be 12 back and 11 forward, and we won't survive as a species. We do this as a species, and we do this as individuals, where we work against ourselves, and we don't have to do this. We don't have to have needless destruction happen around us. We don't have to have a society of plenty while there are single mothers with children on the streets. There is more that we can do, whether it's trying to lift up the people who are on the verge of not surviving, who are living in misery. We can also do it with ourselves. I don't want to cloud my own picture. I don't want to work against myself. And if I see with clarity, and I don't bring in the fun house mirrors, life goes a lot better, and I use a lot less time and energy making it go better.

And that's true for all of us. It's true on a universe level. It's true on a global level, and it's true within each one of us.

How important do you think it is for our emotional health to have peace with nonexistence? I do not really really have a great sense of that, and I don't think many people do. In other words, as is the case in the previous example, there's nobody who intellectually, I mean, no reasonable person intellectually doesn't understand that they will cease to exist at some point. We will all die. Notwithstanding all the biohackers out there. That knowledge, that cortical knowledge, is very difficult to process. It's very difficult to come to peace with the idea. And let's talk about the best case example, which is you live a long, healthy life, and in your 90s, you die in your sleep. You couldn't ask for a better existence. And let's also assume that everything up until that point is moving in the right direction. You don't just die in your sleep, you die in your sleep, having lived a meaningful life and having had wonderful relationships and having raised children and grandchildren who were wonderful people. Let's make this the best case scenario. And yet many of us, I think, still struggle with the finite nature of our existence. Do you think that coming to some acceptance of that is essential for our emotional health?

I do. Whether it's essential in everyone, I'm not sure, but I think it is very important. And there's so many factors that work against us that we can change. So this societal idea that getting old is just so so, so, so awful, and death is something to be feared, it's not clear that that's true. When you see when people are much older and are closer to death, what they fear is loss of control, not death. Maybe we build up a society that glorifies not being dead as opposed to glorifying living well. That would be a nice switch. When we think about health span and quality of life, instead of living in a society where we're so afraid of of death that we just don't want to die, and we're not even paying attention to whether we're happy or not right. I think we could work against that a lot, and we could work against these cognitive tricks, these things we do inside of us that torment ourselves. I don't want the voice of someone critical of me living in my head. I also don't want to be contemplating my nonexistence, because what I do then is contemplate that I'm aware that I don't exist and I'm upset about it.

That's not not existing, right? If you don't exist, you're not contemplating it.

I know. Therein lies the greatest challenge. I tell you, the people I am most envious of are the religious or anybody who believes in an afterlife. If you believe in an afterlife, you have a way to get around that issue. If you don't believe in an afterlife, then you're stuck with that very bizarre idea that seems impossible to reconcile.

I have thoughts about this, and they're not fully formed, but I wonder about that. I think a lot of times people ostensibly have faith but aren't behaving that way because we're in a society where everyone's fearing death and nonexistence. But many, many, many of those people are people with professed religious values. I think oftentimes we're taught religious values when we're young, we identify in a certain way, but we don't really know what do those things mean, what do I actually think and feel. I think when people do have, I say, a deep faith could be something different. But I think our religious values don't really work against that very much. I think it was Spinoza, whose definition of faith was the belief in something that you don't know for sure. It's very interesting when people say they know, like this is my religious values. I know that's true. I don't think that's faith. I don't think our philosophical and psychological heritage tells us that. I think that's a leap of something because we don't actually know. If you think you know and you don't have enough understanding or humility to recognize that there is a leap of faith, then are you doing something that doesn't actually help you?

This isn't me being anti-religious. I think faith is very, very important, but it's recognized in such. There is something I believe, but I do not know that thing. I believe it. Now, that's very interesting. Why does the person believe it? How do we see the beyond ourselves as opposed to just pasting something on that doesn't actually make change? Because What I think I'm trying to say is when people feel very, very sure of something, I worry about that. When people feel very, very sure that there's nothing, I also worry about that. If you think about it, I find it quite amazing that there are so many things that we know a little bit about that fills me with wonderment about what else might be there. If you think about things happen outside of time and space, that's interesting. There have been experiments done where you or I could decide what happened in the past, not figure what happened, but decide. So time, space, movement, the impact of consciousness upon the world around us, this is all so interesting. Even the things we learn about that are going on inside of our brains, the cutting edge of neurobiology and neuroimaging and some of the psychedelic studies and what they've shown going on inside of us tells me, I don't know what happens next.

I don't know that. I may have all sorts of thoughts one way or another. Maybe some of it comes from early education and some of it comes from the faith I was raised in, but I don't know. That not knowing, I find to be very, very hopeful. I don't know what comes next. It doesn't mean that I'm going to rely on anything in particular, but it certainly means I'm not going to despair about nonexistence. I'm not sure of that. I think that's what it tells us. I think that's what Spinoza was writing about. I think what great religious thinkers, not that I've read a lot of them, but when they're writing within religions, they're writing in these ways, too. Maybe that engenders a respectfulness. I think if we knew that there was nothing afterwards, I would hope we could still find a way to be respectful of our lives. But the fact that we don't know what comes next is interesting. I think, to me, that's full of interest and curiosity and hope. The generative drive in me gets activated when I think about dying. Now, it doesn't all the time. It can get active.

I think, I don't know what comes next. I think that's interesting. Things happen outside of space and time. They're certainly not absolute. Our consciousness Can they actually change things, be its own entity in the world around us? We all have different times. Do we have different dimensions? This is out there in the world around us. This isn't pie in the sky. This is academic studies that are telling us these things. When I think about that and scratch the surface a little bit, I go, I don't know. That's interesting. I think it helps me to feel a sense of real interest and excitement about then living the best life that I can live. Because if it's all I have, then I want it to be good. I want it to be the best it can be for me and the people around me. But in taking care of myself, I'm better for other people. I feel invigorated by that, not afraid. I think, again, you see that in people who don't fear death They're happy with their life. They're leading life in a way that they can feel a sense of pride, and they feel humble, they feel gratitude.

They're rooted in that. And there's often a sense of, not always, but there's often a sense of, I don't know. And isn't that okay? Think about how many things we don't know. Can we take care of ourselves and treat every life as precious? This idea that there's nothing special about any of us, but there's something special about each one of us. I think not knowing what comes next and the idea that if we think there is something or isn't, that there's faith involved, that's a thought process. That's a deciding on the part of the person. That comes through interest. I think that engenders us to be better to ourselves and better to other people. I think then we stop fearing death and we stop living in this pseudo cult of I must not die, which is fed by all these fantasies and these places we can get us. Even in literature, I think about no exit, a great play by Sartre, where people are dead and they're watching themselves. That's interesting as a way of learning something through the fantasy of literature. But there's a theme that runs through that, that we're dead and we see ourselves with despair.

I I feel pretty sure that's not happening. It would really make no sense that that happens, right? That there's some punishment of seeing ourselves with despair. Why would it be? It just can't be that. I think if we're open to that, we just don't know. And the literature and the philosophy in the world around us It is interesting things to say, but no one's going to tell us. Isn't that awesome? I think it is.

Paul, I want to talk a little bit about how a person can find a therapist that's going to help them be a guide through a lot of the stuff we've been talking about today. So there are a few facts that people, I think, are generally starting to understand, which is, of all branches of medicine, this is one in which the interpersonal relationship between the doctor and the patient, and we'll broaden it because it's not just about physician-patient, but the therapist and the patient. The interpersonal connection matters more than it matters in any other form of care between a provider and a It's great if you love your dentist. It's great if you have a connection to your surgeon. It turns out to not matter nearly as much. Would you agree with that statement? I don't want to use like as the word. What word would you use for what I'm trying to say?

Rapport. There have been so many studies that show how important rapport is. And yes, it is good to have rapport with one surgeon, but it's not the primary factor, presumably. Rapport is very, very, very important, and one might argue indispensable That's why you see studies that people can come at things from different perspectives. You think about the anger, how Andy or Katie may come at it is, Hey, let's talk about getting a space between the anger and the response. They also want you to understand it, too. I might come really from the understanding, so you go to a place of humility and gratitude, but I want you to pause, too. We're not doing different things, but we're doing what we're doing from very different perspectives that will feel very different if you're on the receiving end of And that's why when people say, Well, if rapport matters and does it matter, then maybe it doesn't matter what those people are doing. But that's not true. The presumption is the therapist knows what they're doing. They're coming at the skilled part of it from different perspectives, but it doesn't matter that the therapist knows what they're doing if there isn't rapport.

So let's take that as a necessary but not sufficient piece of the equation. What are other things that a person should be asking themselves? And we can handle the following questions separately, but I want to address both. A, scenario one, you are going to seek the help of a therapist for the first time. And B, you have been working with a therapist for a long period of time, and you want to evaluate if this is productive. And the impetus for B is, I can't tell you how many people I've met in my life who, even to my completely untrained eye, which tends to be more critical of self others, I look at them and I think, what is your therapist getting paid for? You are having the exact same problems today that you had five years ago. If anything, you seem a bit worse. And yet you tell me you're seeing somebody every week. Again, I don't say that to be judgmental. I say that from a place of, I want you to be better. And maybe somebody listening to this identifies with that. So anyway, again, feel free to tackle those separately. But what I want to understand are, what are the questions questions a person should be asking themselves of the therapist, and perhaps of themselves, in those two situations to make the best choice?

A, how do I find someone de novo to start? And B, how do I decide if I need somebody new?

There's a lot of specifics I could say about those things, but I think I would start them in a different place. I would start with an overarching principle because I think the principle always applies, and then it can get at a lot of these things underneath the principle. I would ask, does one plus one equal more than two? The way that mental health was thought about, say before the end of the Second World War, our minds were conceived of as very transactional. So they would say, even now, I put something out there in words, you take it in, then you put it into your brain, you put something out in words, I take it in. Even though they would acknowledge we're doing something, the thought was it's very very transactional. And what we see is that's not really the truth. I think Viktor Frankl's writings after the Second World War were really an impetus to really see this and led to a whole different type of psychotherapy that was called existential psychotherapy. It still is existential psychotherapy, and it does it map to the existential philosophers, exactly. But there are principles there that are around shared humanness.

Do you feel like one plus one is more than two? When you're with the person, you're going to thoughts and feelings and ideas, and that person is going to have thoughts and feelings and ideas, too. Does that create something more between the two of you? The thought is this is how we find meaning in life, that when we're with someone we love, for example, it's not just it is us and it is them. There is an us. Like you are you, the other person is who he or she is. But together, there's something different that each isn't going to find on their own and that each isn't going to find with another person. In this case, the dyad is special. The two people together more than the sum of each of them. I think that's true for satisfaction, enjoyment, learning in human relationships. I think because these principles run wide. The same thing that would apply, applies here, too. There should be someone who's present and who's work with you. There's a shared humanness, and you're figuring things out, and you feel the greater than two of the two people in the room. I think That's a lot of what rapport is.

I mean, some of what report is this positive regard of the other. They're pleasant trees and nice. They're ways we can build rapport. But I think they're more on the surface. They're important. But that's not what makes real rapport when someone is helped. I think what makes real rapport is the fact that here I am with you, and there's something different with us than there is in just the sum of us. Something new and different is here, and I feel that when I come in the room to see you. I think you feel it, When I come in, it's a real interest in me and a real applying of one's brain to the other. Whether we call that rapport or I just feel great about that person or, Man, it's so dynamic, there is something there that is the therapist really being present. I think that that's an obligation of the therapist. We're supposed to know technical things, and of course, there are things that we have to learn, but we're supposed to give of ourselves in a way that has us truly be present with the person. If you figure that out, whoever the person is, should I have this person be my therapist, or should I leave this therapist and try something new?

I mean, if you try that on for size and it doesn't fit, you should probably change something.

How long in the context of the first scenario, which is somebody looking for a therapist, how many meetings with a person do you think you need to have before you can evaluate that?

I talk about this a lot. You can know if things really aren't right. If a person is approaching the therapist therapy process and they really want to be there and all of that, sometimes you can just tell if you're not going to resonate with someone. It looks like someone who's not making eye contact, for example. Hey, you can tell, or you just feel an awkward sense. Sometimes this happens with people, and sometimes you could know that, Okay, that's not going to be right. But again, be fair and reasonable about it. Do you really want to be in therapy? If you don't, then maybe you're going to find something wrong with everyone. But if you really bring yourself to the process, then I say you can tell no sooner than you can tell yes. Because in the first couple of what's going on is you're trying to build a relationship and people need to get to know one another a little bit and how they respond and what their mannerisms are and if they have a sense of humor and how much emotional valence is inside of them. It takes time, so there's a little bit of a dance like there is in any new human relationship.

The thought is if something really rubs you the wrong way and you're looking at that honestly, you could probably tell no first, second, third, along the line. If not, give it a little bit of time, five, six, seven, just to see, do I feel like I'm resonating with this person? Are we really getting somewhere? Because again, the progress and the perception of progress is not linear. Sometimes it is four sessions, I'm not so sure. Okay, so I'm not so sure. Let's give it a couple more because sometimes by the six, the person feels like it's falling flat, and I don't feel that there's one plus one is not equaling more than two. Or sometimes, the stuff we did early on is clicking a little bit, and now it's only session six. It's two more than four, but they start really feeling something. There's a process to that. But if one just applies those principles, then again, I think there's a process to it, but it's also a process that you can really apply of, I'm looking for things that are real negative. That person isn't making eye contact, that's bad. Or I really feel it odd.

You can feel it, acknowledge it. If you don't, be observant, be patient. What's going on inside How are you? How are you feeling? Are you feeling help? Do you feel what gets called a holding environment, that the space when you go in is a safe space? You can be open and honest because so many times people fear criticism, where they feel that they'll say something. This is often true with trauma. They'll divulge something, and then the other person will recoil in horror. And this happens a lot where someone will just talk about...

The worst thing imaginable.

They're saying it, and you'll see this is known in therapy education. But if you do therapy, if you see this in people. They're surprised. Oh, my God. I said that. And then they're surprised that the other person, that I didn't recoil from them. Because inside of themselves, they've held that this is something shameful and someone else should recoil because they're carrying shame from it. But if you develop enough of a holding environment, enough benign regard, enough real humanness with the person, then that can come out of them without them having even decided. It just naturally flows out because they know that they're in a safe place. And somewhere inside of them, they know that other person isn't going to recoil, just like they wouldn't recoil, just like you're saying, what would you say to your best friend? So somewhere inside of you, you know that you don't really want to be saying the things you're saying to yourself. You're going to know that because why would you say it to yourself and not someone else? But that's different than having an experience of it. In having an experience, in your case, when you were making the recordings, you're having an experience of a more accepting self.

That's great. We can also have that experience with an other who represents a more accepting self. If the other person doesn't recoil, that's right. You're not really recalling from that either.

No, I think that's actually an interesting example because I really felt uncomfortable sending those recordings to Katie. I think initially I said, Well, I'm uncomfortable because I hate that I'm wasting her time. I'm up her phone with text messages of these recordings, but that's actually probably less what it was. I think it was more, I'm ashamed of the fact that I'm doing this, and I'm ashamed of how difficult this is, and what is she thinking when she gets this? Again, this is a narrative you're making that's incorrect. If a good therapist isn't, none of those things are true, but that's the thought you're having.

Right. So you have to know that she really wants you to send them, that she really wants you to send them, and she really wants to help you, and she really feels good about you. She sees the goodness in you. And then it lets you do something that exposes the shame. I think, part of what you feel ashamed of is that you're doing that to yourself.

Yeah, no, the shame is that this is so hard to do. This shouldn't be hard to do. It's, I shouldn't be doing this to myself, and therefore this exercise, A, shouldn't be necessary, and B, it should be a piece of cake, and it's not.

So now it's witnessed because think about this competing shame. So on the one end, the shame of not being perfect leads you to do something shameful to yourself, which is to be berating yourself. Look, if you did that to someone else, we would say, Hey, that's a good reason to feel ashamed, to talk to somebody like that just because they broke something. We say, Hey, that's not okay. Why is it that you shouldn't feel ashamed when you're saying it to yourself? Shame can help us by changing behaviors. But now you have competing shame. Should you be ashamed that you're not perfect? And it's good that you're beating up on yourself. Should you be ashamed that you're beating up on yourself? Because it's okay that you're not perfect. This is part of what keeps us in stasis. But then she, as the person she's, she's not completely separate from you in that way. One plus one is equaling more than two now because she becomes a little bit of an auditor or a metric of what really makes sense here. And her reflecting back to you that, Hey, you're worth treating better than this. This is not okay for anyone, including you.

It's not okay. You're not the only person who gets to be beaten up this way. Then part of that is her seeing that. It makes it easier for you to change because then you put the shame in the right place. Like, right, if I feel ashamed I'm doing this to myself, I want to stop. If it's going to take a long time, I'm going to let it take a long time. I'm not going to be so ashamed it's still here in three weeks that I stop. I'm going to keep doing it. But part of what lets you do that, it's the exposure to the outside person who you trust because then that person becomes a barometer of what's real and true here. Then it helps us get our own minds into place. Like, Oh, right, right, okay. I do get this. It is okay that I am not perfect. I do not want to beat up on anyone like this, including myself. Now, you've got the resolve inside of you to do it. Why? Because you've been validated. Whereas before, you might not have been so sure if the shame is with the lack of perfection or with the self-taught.

Let's now talk about another question around the person who's been in therapy. They have the therapist. How often do you see a therapist whose rapport is in the way that they think of rapport, which is getting along, but they're not hitting the one plus one is greater than two? That can be difficult to quantify. But the rapport is such that it's almost enabling the behavior in the client or the patient. And there's no progress being made. Yet the client feels like, hey, this is great. I have a therapist. I love my therapist. I see my therapist all the time. I go in there once a week and tell them everything that's wrong. And it feels really great to do that. But if an objective person, if you were sitting there looking at this, you'd say, yeah, but things aren't getting better. Is there value in just having a person that you pay to listen to what's wrong? Or are you paying this person to help you become better at dealing with whatever it is that's going wrong? Question one, is the first critical step in that, that the person themselves must recognize that I need to reevaluate this relationship?

And if so, then what are the tools to evaluate that?

Unfortunately, yes, in the example that you gave, because it shouldn't have to come to that. Therapists are people, and we know that whatever occupation you take, there's a significant subset of people who aren't giving it their best. I mean, that's part of humanity, too. So the therapist is really transgressing something there that should not be transgressed.

And you see this, right? I'm not just making this scenario up.

Sure, it happens a lot because, again, not everybody brings their best to their work. For some therapists, it's okay. They'll let the person come and go, and they rationalize, well, they're still clicking along, and they're doing okay in this way or that way. And they'll rationalize that what they're doing is a non-doing. They're not actually doing anything. The obligation for the therapist is to know, I know this person is benefiting from this. I see where we're going. So even if I don't see it now, I might see, I don't think there's going to be any change for the better in 6-9 months. I have to accept that from week to week Because I know where we're going to get to if we do the work by the 10th month. I mean, it's just a more complicated situation. But the therapist has to know we're either achieving something now or we're heading towards achieving something that's changing this person. It's my job to be active about that. It's my job to not get complacent or if I see that person wants to get complacent, to talk about that with them. It's just a harder job. But I think it's the therapist's obligation to do the job that way.

Now, when that doesn't happen, then we end up in this situation you're describing. We're saying, Hey, this person is in this situation where things aren't getting better. I think putting a full stop to that, like, What am I doing here? What am I paying for? Sometimes that's a good question. What are you paying for? You go buy a gallon of milk, you know you're paying a gallon of milk. You go for an hour of therapy. Are you going for an hour of, I want to understand myself and make change? Are you going for it's an hour I talk about all the things that are making me angry the last week, and then that person gives me a little bit of sympathy and I'm no less angry? To really look inside at what the person is serving. Also, how good does it feel? Comfortable does it feel? It shouldn't always feel good and comfortable. There should be times when you're talking about something that's not easy to talk about or you're crying in therapy, you're upset in therapy. It's supposed to be work. It doesn't mean it has to be work every moment. Although there's a lot of fun to it, too.

I have great fun doing therapy, whether I'm the one doing it with someone else or I'm doing therapy with Gregory Hamilton has been my therapist for, gosh, 13 years or so. It's fun a lot, too, but sometimes I'm upset or I'm crying or he says something to me or I say something to someone, it's like, Whoa, that's okay. I'm going to take that in. It's supposed to be work. Everything in life is that way, too. If it's too easy, that's not a good sign. If you feel a thread bear, that's a... He said it's hard to quantify when one plus one is greater than two, but you do know it often in human relationships. You just feel good with someone. There's something where you're more than the two of you. That's why people want to spend time together. It's why people become romantically interested in one another. There's a lot of that going on in aspects of human relationships.

Let's dig into that a little bit more because it really is... I've never contemplated that at all. But as you pointed out, you take two people like you and I who are very close friends. It's such a clear example of that, the accretive nature of the interaction. But we are friends, and yet we don't necessarily feel that a therapist and patient should be friends. What are some other questions a person can ask to try to get at that accretive nature of coexistence resistance.

I'd go back to the framing of it. How do we decide people are friends? Can't quantify all of that. Well, there's something there. They know something about one another. They're interested in one another's well-being. They have points in the past to tether to. That's why however much I may think about myself or you may think about yourself, there's something different that happens when we're together. I leave feeling different. Why? Because I saw you. Not because I saw someone. It would be different if it were someone who's not you. That's because we have a real human relationship. Now, we call that friendship because that's what the language applies to it. That shouldn't be different in therapy. It doesn't mean that these people are friends and they're going out for dinner together. It's not that. It's that there's a human connectedness and there's something that's greater than the sum of the parts. If we look at friendship as an aspect of human interconnectedness and a human ability to see and feel and be present beyond the self, then that happens in friendships, that happens in romance, that That happens in parent-child relationships, that happens in a therapy room.

If it's not, then I think there's a problem. I think there is supposed to be something greater than the sum of the parts. Whether we say one plus one should be greater than two, or we say there's an element of friendship in therapy relationships. We can say it any way we want, but it has to be more than just the sum of the parts. That person has to have real regard and interest in the person, have some aspect of the friendliness that friends feel when they're together. The existential therapist understood that the brand of therapy that when it was thought everything is transactional, where you could sit behind the person. It's not as if there's nothing that could ever be gained by that, but that can't be the baseline of it. What has happened since then with people like Harry Stack-Sullivan or the existential therapist that came after Viktor Frankl's writing, Rauwamay and Irvin Yalm, and they were doing something different. They were like, We're humans being with other humans. That's real. I think that that is wonderful. When I learned that in my therapy training, when that element was added, like, Oh, it's okay to be human, because I had an existential therapist who was taking care of me at the time, and I also had some mentors who were, I thought, Oh, okay, we have to think about the other person.

The session is about the other person, but we're both humans, and it's going to help them if they see that in me too, every now. Then it makes sense to disclose something, to talk a little bit about yourself in the service of the other, to let the person know something, to let them know that you are not I think a reason you and I are able to help people is I don't think either one of us tries to put out there that we are not either now, recently or potentially suffering through anything someone else out there is suffering through. I think there's a humanness to that that's just real and honest. By the way, it doesn't feel better, I think, to hide behind it, to pretend. People can always hide behind something, whether it's socioeconomic or it's a power differential, it's a position in life, but that doesn't make anyone feel any better. The truth of it is, for example, we do share humanness with everyone. Anyone can get trampled by the society around us. Lightning can strike us. We all suffer. We all have struggles within us. So acknowledging that we're all human and we're trying to help one another, but we're coming at it from a place of acknowledging what's going on inside of us and that we are not perfect.

That's why therapists learn from their patients. Good therapists learn from their patients. Absolutely. I can think of the life lessons that come. Why? Because I'm human, too, and I don't have all the answers. Hopefully, I have some education and training that can let me help you, but also helping you will help me, too. That's true.

I was talking to one of my colleagues before this podcast about trying to organize around a few different phenotypes of people that we interact with in our practice who, again, each of these examples, which are caricatures, of course, are people who think everything is fine with respect to their mental health, but there's an externality. Phenotype one is the workaholic. We've talked a lot about this person. This is the extreme achiever. This person is so successful on the outside. Everybody just assumes everything is wonderful. But a lot of times, frankly, when you go from the street to the porch, you realize maybe that's not entirely true. And once you step in the house, you realize that's not entirely true. Another one we've also spoken about is the endless optimizer. So incredibly rigid and controlling of everything in order to drive towards perfect health, as an example. Then you have the very anxious person who really struggles with the fear of the future. And the fear of the future can be short term and it can be long term. And again, we should have some fear of the future that would allow us to do things that are productive.

But obviously, I'm talking about this in a negative way. And then, Perhaps, at least for me, the most difficult phenotype is the denier. So this is a person who, by any reasonable metric, is suffering. But their barriers to accepting that are so high that you can almost make a cartoon about it, where you see a person who's missing an arm, and you ask them if you can help them because they can't do something that would require two arms, and they look at you like, What are you talking about? Of course, I can do this thing. I have two arms. Well, but you're missing an arm right there. How do you think about someone, be it a friend, be it a physician, be it anybody, trying to help and get through to any of these these phenotypes, to put the thin edge of the wedge in there such that they can at least make a tangible step towards self-help?

Well, I think the first thing to do is recognize Okay, that there's a problem. Then you go back down this idea that there are these cupboards in the conscious mind and the unconscious mind. That if we go and look and scrutinize what is going on inside of us, or we have curiosity about what is going on inside of someone else, that we're going to find the answer, that this is not a mystery, that just like a Sherlock Holmes investigative process or a math problem, one can look at it and learn things. Think about the first example, a workaholic Again, you didn't say someone who works really hard and achieves high, but a workaholic. So even the word, by definition, is a problem. So what are workaholics doing? Well, oftentimes they're avoiding something. That's why alcoholics are trying to avoid something by drinking to get away from it. We understand that, but it's no less true with workaholic. There's something going on inside that person that they're afraid of, that they're suffering from, that they're ashamed of. Something is driving this behavior. I think, what are you avoiding? What are you trying to get away from?

Because workaholic doesn't mean you work very hard and you achieve at a high level. Workaholic means you're working when it makes absolutely no sense to work. So what are you escaping from? So then I think there's a defense here that is usually avoidance as a defense. And there's other defenses that come along with it. The person can put blinders on themselves, go in one direction, feel that that's good enough, but boy, aren't they seeing what's on the other side of it or feeling what they would feel on the other side of it. Then that becomes a point of curiosity. Is there avoidance? What is that avoidance? What's going on inside that person? Then you think, okay, with someone who's optimizing, always trying to perfect, there's something different going on there, which is probably more rationalizing. We all know that things get to a place that's good enough. Everyone knows that. If the person is still trying to make something that's really solidly good enough, perfect, what's going on there? What are they serving inside of themselves? They're going to soothe something. Some anxiety then gets soothed because they do something that's irrelevant. Let's go look at why the need to focus on optimizing something that's already good enough.

There's other things to do in life. There's other ways to spend that time and energy. Why that focus? It's a process of curiosity. When people are very, very anxious, then where that leads us is what's going on inside of them. They may be, younger people in my practice call it future tripping, anticipatory anxiety. Is there a way that that person's fear about the future shuts them down so that they're not doing anything in the present and they don't have to be afraid that what they'll won't work in the future? That doesn't go well, but we get into those places. So what is that anxiety inside? What is it about? Why is it so high? So then again, we become curious about that. Denial is the hardest one. When we think of maladaptive defenses, because how do you get someone around maladaptive defense? You're trying to help them understand. So if you're rationalizing, there's a little bit of a place we can grab onto that. Okay, you're rationalizing. Some of it makes sense, then it doesn't. But denial can be very, very cut and dry and very frustrating to come up against. I don't know if you met Peter Grover, who's a therapist within our practice who's very, very experienced.

Peter has a sign on his wall. It says, How's that working for you? Because that's his mantra. He's very, very good at helping people who are in that so difficult denial position by helping them look, Well, let's just look at how's it working for you? Because the idea is then the person's at odds with the therapist. If you're like, how's that working for you? You can then together look out at it. Luston Havens, I had to meet many years ago, who in an era when most therapists were sitting behind the patient, would sit next to them and look out at the world together. You're trying to do that. How's that working for you? It's like, okay, I hear what you're saying. It's not saying it's right or wrong, whether you're working or you're doing this or the other. Let's just look at how it's working for you.

That can't really be even answered without some introspective capacity. I've interacted with people where maybe I didn't ask that question point blank, but I can almost to imagine that if asked, they would respond, Great, everything's great. Can't you see? Everything is great. I totally understand that of the four phenotypes described, that one is hands down the most difficult. I'm just wondering if the people around individuals like that, if they care about them and they want to help, how can they help them probe even further? You hear the term intervention. At this point, you just get everybody in the room who knows them, and you just have that riveting intervention. What's the equivalent of state here?

It's hard. Sometimes you can come at it. The idea here is the person is not letting you see with them. You're across from them metaphorically. What you can do is then to tell them, to say to them, How you see it. Because I can't impact you. You're not letting me. Barry, there's nothing wrong. That's your story. You're sticking to it. But presumably, if one is having that conversation with a person, one plus one is equaling more than two. That's why you're sitting across from them. There's some emotional investment. There's some respect. There's some love or consideration. There's something there that when you say, Hey, I just understand that, and I hear where you're coming from, and I hear it loud and clear. I just want to say to you that from where I sit, as someone who knows you, cares about you, loves you, whatever it may be, what I see doesn't seem okay to me. I just want to say this. I'm trying to force it on you. People sometimes will remember that down the road. Sometimes you're like, Look, I can't help this person right now. But what I think I can do is maybe put a seed in there that may come about later.

Sometimes I'll see this with someone who's drinking very heavily and not acknowledging. I still feel good. I don't feel any different, so nothing can happen. Now, we may have a set of underlying labs that we can look back from and we see where those numbers are trending. It's not hard from the outside to see, but the person is like, I don't feel any different. There's nothing wrong. Even then, sometimes, well, if I can, I'll try and put in an idea of, look, at some point You're going to start feeling something different. At that point, remember this. We're acknowledging, you can't get through to everybody. That's okay. If you can't, don't keep trying because look, I want to tell you how this is going to be bad for you. That person has long turned you off and you turned you out. You can't get anywhere with them. But if you do them, it's okay. I get it. I'm not the person who says you stop drinking. That's not me. That's not what I'm doing. What I can do is maybe plant a seed that I think you're going to start feeling something. At some point in time, this is going to start feeling different.

Remember this then. Sometimes people do, sometimes they don't. But a lot of times when people get help, you do see that they've taken that inside, sometimes from someone else. Sometimes I'll see it in my own work where someone who I thought things ended very badly and the person wasn't helped and they left, and I tried to plant a seed, and then they come back in a couple of years. You know, I thought about that. And like, wow, that feels great. It's a proof of concept that you're doing the right thing by planting these seeds. But more often than not, we see someone else has planted a seed. Maybe that was another therapist, or it was another friend, or someone else said that, or someone said a long time ago, they read it in a book. If we can plant seeds in people who are in denial, those seeds may grow. But we have to understand when we can't do more than that and stop. Otherwise, we could drive the person away and prevent any help I'm coming.

One final question I just want to ask you, Paul, is about how you manage internally the challenges of what you do in the sense that you work with all sorts of people across all sorts of spectrums. And obviously, we didn't talk about it today because we've spoken about it a lot in the past. But you're going to be very quick to look for the trauma in a person's life that probably shaped many of the adaptations that exist today. And in doing so, sometimes those things are very sad and they're very tragic. I just wonder how you manage the sadness around that for yourself. I think about what it was like being a resident. Patients would come in and they would die, trauma victims. Someone comes in in a car accident and they're dead. You take care of them and can't save them. We don't really get taught how to manage that at all. I found that to be, hands down, the biggest failure of our training system. Perhaps that's changed. But certainly, when I went through, there was absolutely no discussion, even, of that. I remember being reprimanded for going to the funeral of a patient.

The idea being like, that's a line you never cross, and you have to block that stuff out, basically. How do you deal with that?

I'd start by saying, I agree with you. I think at least in our era of training, medicine did a lamentable job of that. If you think about medicine, hopefully selecting for empathic people or compassionate people. When a person is built that way, that one plus one is more than one. So you feel part of a we. If you're taking care of someone and they die, you're not that person. But magically, it's what goes on in our heads. We feel part of them because we're a we. We see that with people we really love who are close to us. They're part of who we are. We see this in settings where we're helping people, too. I don't know if you went through this part of it. I remember when you were talking, I remember very vividly being an intern and having to really tell myself, I am not this person because they start feeling like, Oh my gosh, I could see this person is suffering. It's easy to lose those boundaries. To be able to say, I'm standing here, that person is there. In fact, the only way I'm going to be able to help them is I have to know that I'm not that person.

But it wasn't easy. I remember one of my co-interns, and I remember he and I really talking about that, and we were trying to do it for one another. Okay, you come down a little bit like, You're not this person. Let's step back from it, catch our breath, and try and help the person. He probably remembers we did it for one another. For me, it starts with that because that's a physical separation. Then the idea that I can mentalize a lot, meaning think a lot and feel things. We can all do this, but you do this when you're a therapist, you're feeling what other people are feeling, you're feeling for them. It's easy to keep that in your mind too much. Then just like if we picked a word and said it 5,000 times, it'll be in us tomorrow. If there's something you don't want to do and you repeat it 20 times, you're more likely to do it again. The same is true when we can't bound ourselves well enough from the suffering in other people. This is why people have post-trauma syndromes from vicarious trauma. I mean, this absolutely happens. The brain is changed.

There are biological changes, behavioral changes, and all of that trauma is vicarious. This is why we see the levels of depression and suicidality and substance use is higher in people who are giving care to others. It is so important that we have these boundaries inside of us, and they have to come, I think, from this place of balanced drives and gratitude and humility. I'm so grateful. I get to know other people. They share things with me. I can help them. I can learn from them. That is such a wonderful thing that it helps me to accept the other side of it, which is sometimes things that are very, very hard to hear or very hard to get out of our minds. I have to then have the humility that I am human too. If I keep this in my head or if I'm really mad about this thing, this thing that happened to somebody, we see the most awful things people can do to one another I know these things happen. I can fester on the anger, the frustration, the misery of this, and I will hurt myself. My obligation to myself and to the people around me that I care about in the world, the people I love or people I know and I like them.

I want to be healthy. I want to be at my best, and I have to be able to maintain these boundaries inside of me, which means have the discipline to stop thinking about that. Know that take stock of, I'm doing the best I can for that person. I'm still worried. I'm worried it's not going to have a good outcome. Am I doing what I can do? I can. There must be something else that comes into my mind. I find it is easier to do that as I focus more on the balance of drives. I'm being generative. I'm asserting myself. I'm taking pleasure in what I'm doing, and I feel gratitude for what I'm doing and the humility to know that if I don't take care of myself, it'll kill me, too.

Paul, I want to thank you again for not just making the trip out, but more importantly, of course, sharing all of these insights in a manner that's incredibly lucid and helpful. I look forward to doing this again because obviously we will.

I do, too. Thank you so much for having me. It's wonderful to see you, and I so appreciate being on the podcast. Thank you.

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