190 - How to heal from trauma and break the cycle of shame

Conti: here is the great news — you do not have five problems because people will present saying you cannot help me, it has been going on for years and I have four different problems. So here is the great news: it has been going on for years because it has never been looked at, so it is not surprising it goes on for years. And you do not have four problems, you have one. You do not have depression and sleep disturbance and panic attacks and alcohol abuse as entirely different problems — they are arising from trauma. And I may say that because we have had a couple of conversations where the person told me how none of those things were present before the trauma and all of those things are present after the trauma.

Conti uses the childhood metaphor: a clothed tree in a dark room looks like a monster. The more you look away, the scarier it gets. The moment you turn the light on, it is just a coat on a hook. Shame works exactly that way — it instructs us not to look, not to share, not to even think about it. Yet the antidote is a light: I have never worked with one person and cannot call to mind a single case where shedding light on shame and all around it — looking in all the dark corners and really bringing it to light — has ever been anything but extremely helpful to the person doing it.

Conti: we have to prepare that person that absolutely you can get better but it is going to take place over time, and you do not have to be afraid when those thoughts are still in your mind. I have worked with people who started treatment even before I met them, with among the most severe repeated negative thoughts and feelings, who may have been doing really well for 10 or 20 years — but put them under enough stress and it will still come: 'you are nothing and you should kill yourself.' But now they know well enough — that stuff dies hard, as one person said — they are not afraid of it at all, because they understand they said that thing to themselves a hundred thousand times, it is still going to come back every now and then, it does not mean anything.

Attia describes the problem: there are patients I suspect have an issue but as I approach it there is complete denial, or other patients who on the surface accept it but then cannot engage. Conti's framing: you are looking for people whose actual behavioral choices are running countercurrent to what they are presenting for. The person who really wants to stay alive because they love their grandkids but has diabetes and this is their third hospital admission in two years — that person does not want this to happen. And to look at that and say maybe there are logistical barriers, and then very often where that process arrives is there is something preventing that person from taking care of themselves. That is the light bulb.

Conti: I have written many more times than I can count on a prescription pad 'no more news.' I see a person's health who I may have known for years really deteriorate over a couple of months of paying attention to something so intensely distressing. We have had more crises than we can shake a stick at in recent years. Someone who had three or four really acute traumas but does not have a post-trauma syndrome — but who is really a setup for it — starts paying intense attention to traumatic things they are seeing in the world around them and now they have a syndrome. And the DSM excludes them because they do not meet the occupational-context criterion for PTSD.

Conti served as medical director of a clinic running substance use groups and deliberately did not separate by substance. Knowing the health histories: roughly 80% commonality as a driving force was trauma. Sophisticated residential trauma facilities already do this — Bridge to Recovery's organizing question is what is your trauma, not what is your drug of choice. The science backs it: psilocybin, alcohol, cocaine, gambling, and work addiction all hijack the same machinery in the brain.

Conti's analogy: the Delaware-Raritan Canal. People could fish artifacts out of it for years. But when they drained a whole section — my goodness what they found. The helping potential of these substances can get us to places of really seeing what is going on inside of us. There is a potential here for even a revolution within the field, but we have to safely and effectively incorporate those arrows into the quiver. The resistance Conti observes is from practitioners who see MDMA and psilocybin as threatening to their power within the discipline — itself a manifestation of the institutional shame that prevents the field from facing its own limits.

Conti describes: the epigenetic research shows that not only is it not a one-event limited-to-a-day experience, but it carries on throughout that person's life, impacts the society in which that person lives, and gets passed on to the next generation. So a woman who was raped has a child three years later, and the genetics expressed in that child are impacted by the trauma that happened three years before conception. This gives trauma research an anchor that Western medicine requires — observable, measurable, heritable biological change — and removes the last refuge of skeptics who treat psychological trauma as subjective complaint.

Shame loves alcohol excess, shame loves an internal dialogue that tells you that you're not worth anything. These things that shame loves are then cultivated in ourselves and applied to further walling off, further pushing the problem down. That is why the best route is not just to shift how we are handling care — we need to change the sociological aspects of this and look at what many many of us have really significant trauma that has overwhelmed our coping skills and changed how we view ourselves and the safety of the world around us. There is no shame in this. Conti told a room of 300 physicians that psychiatric medicines had really helped him, and roughly a third of the audience recoiled as if he had said something shameful — evidence that shame pervades even the professionals tasked with treating it.

Conti: the traumatic response saved your life right — we are built to recoil and protect ourselves from dangerous things, which is why trauma leads to avoidance and hypervigilance. People become more afraid of the world and less likely to engage. If you think about how these systems grew in us — in small groups, if you ate something that made you sick, never eat that again; if someone from another tribe attacked you over that hill, don't go there again — staying close to home was right. But in the modern world those things do not make sense anymore, and the walled-off psychological abscess is spinning off symptom after symptom. A tendency toward a little too much alcohol soothing a couple times a year becomes three, four, five, six, seven days a week as desperation grows. That tendency toward avoidance becomes unable to get out of bed.

Conti: chronic trauma of immensely high expectations of self, often placed upon self by self but aided and embedded by external forces, creates immense senses of insecurity and vulnerability. People laboring under that for long periods of time can find an outlet for control. In many ways that is often what the signs and symptoms of so many mental health issues are — an attempt to find control. Someone finds control by tapping five times when they think a negative thought; someone else finds control by restricting what they eat. The roots of that are always trauma. The facilities who treat this already know: when you actually show up at a trauma facility, they want to understand and treat your trauma — they are not concerned whether you have the magic card of entry of PTSD.

Conti's analogy: the Delaware-Raritan Canal. In colonial times barges traveled it and artifacts were always being found by fishing. But then at some point they drained a whole section of it, and when the section was drained — my goodness what they found and what they saw. The helping potential of these substances can get us to places of really seeing what is going on inside of us and shifting how those brain pathways — which have been so changed, and the science tells us this — can let people reorient much much faster. The resistance: many people or organizations wielding traditional psychiatric care see MDMA and psilocybin as threatening — as if the power of these resources makes a lot of the tools they wield seem a little bit paltry by comparison. Conti frames this as itself a manifestation of the institutional shame he has been diagnosing throughout the conversation.

Conti: more and more people are feeling desperate and disenfranchised, feeling like they cannot make their way in the world. People who have good jobs feel that job is running them ragged in a way that they cannot take care of themselves and their families, and they feel the same desperation as a person who does not have a job. This desperation builds anger and frustration and resentment and depression and panic, and that makes it much more appealing to soothe in the short term. Basic psychological fact: the more pain you are in in the short term, the more you are going to choose a short-term solution without any consideration to the long term. If I am absolutely desperately miserable and you have something that can make me better right now, I am not going to ask what that may do to me tomorrow.

Conti served as medical director of a clinic with running group programs and deliberately did not separate groups by which substance was used. Knowing the health histories, roughly 80% commonality as a driving force among everybody in the room was trauma. When we parse things out too much we tell the person that their burden is so much about them — 'I am an alcoholic and I am a rageaholic' — and that language is often so stigmatizing that it becomes the identity of the bad thing about you. As opposed to: look at what has happened to us along the way that leads us to this place. The sophisticated trauma residential facilities already do this — Bridge to Recovery: their organizing question is what is your trauma, not what is your drug of choice.

Conti: the psychotherapeutic modalities are so very very different but if you look at primary predictors of success it lies in the rapport. The rapport, the trust, the mutuality generated is what creates the holding environment. I am really scared of this and it is intimidating but I am going to come here and this is a safe environment and you are a safe person and you want to help me. And I do not feel bad when I am sitting across from you. That is why most of the people Conti works with acknowledge their own trauma — not to center themselves, but to create the sense of mutuality that lets the patient tolerate the distress of opening the abscess. When I pack up my trauma at the end of my psychotherapy session I know I am going to come back next week and make more progress partly because the person I go to for therapy makes me feel helped and understood.