Where are the darkest places you've ever gone in your life?

The following is a conversation with Carl Diceroth, professor of bioengineering, psychiatry,

and behavioral sciences at Stanford University.

He's one of the greatest living psychiatrists and neuroscientists in the world.

He's also just a fascinating human being.

We discuss both the darkest and the most beautiful places that the human mind can take us.

He explores this in his book called Projections, A Story of Human Emotions.

I highly recommend it.

It's written masterfully.

This is the Lex Friedman podcast.

To support it, please check out our sponsors in the description.

And now, dear friends, here's Carl Diceroth.

You open your book called Projections, A Story of Human Emotions with a few beautiful words

to summarize all of humanity.

The book draws insights about the human mind from modern psychiatry and neuroscience.

So if it's okay, let me read a few sentences from the opening.

You got to give props to beautiful writing when I see it.

Quote, In the art of weaving, warp threads are structural and strong and anchored at

the origin, creating a frame for crossing fibers as the fabric is woven.

Projecting across the advancing edge into free space, warp threads bridge the formed

past to the ragged present to the yet featureless future.

Yet featureless future, well done, well done, sir.

The tapestry of the human story has its own warp threads, rooted deep in the gorges of

East Africa, connecting the shifting textures of human life over millions of years.

Expanding pictographs backdropped by crevice ice, by angulated forestry, by stone and steel

and by glowing rare earths, the inner workings of the mind give form to these threads, creating

a framework within us, upon which the story of each individual can come into being.

Personal grain and color arise from the cross threads of our moments and experiences, the

fine weft of life, embedding and obscuring the underlying scaffold with intricate and

sometimes lovely detail.

Here are stories of this fabric fraying in those who are ill, in the minds of people

for whom the warp is exposed and raw and revealing.

What have you learned about human beings, human nature and the human mind, from those

who suffer from psychiatric maladies, for those for whom this fabric is warped?

And one thing we learn as biologists is that when something breaks, you see what the original

unbroken part was for.

And we see this in genetics, we see this in biochemistry.

It's known that when you have a mutated gene, sometimes the gene is turned up in strength

or turned down in strength, and that lets you see what it was originally for.

You can infer true function from dysfunction.

And this is a theme that I thought needed to be shared and needed to be made communicable

to the lay public, to everybody, people who, which is, I think, almost all of us who think

and care about the inner workings of our minds, but who also care for those who have been

suffering, who have mental health disorders, who face challenges.

But then more broadly, it's a very much larger story than the present.

There's a story to be told where the protagonist really is the human mind.

And that was one thing I wanted to share as well in projections, is that broader story,

but still anchored in the moment of patience, of people, of experiences of the moment.

Is there a clear line between dysfunction and function, disorder and order?

This is always debated in psychiatry, probably more so than any other medical specialty.

I'm a psychiatrist.

I treat patients still.

I see acutely ill people who come to the emergency room where there's no doubt that this is

not something that's working well, where the manifestation of disease is so powerful,

where the person is suffering so greatly, where they cannot continue as they are.

But of course, it's a spectrum, and there are people who are closer to the realm of

being able to work okay in their jobs, but suffer from some small dysfunction.

And everywhere in between.

In psychiatry, we're careful to say we don't call it a disease or disorder unless there's

a disruption in social or occupational functioning.

But of course, psychiatry has a long way to go in terms of developing quantitative tests.

We don't have blood draws.

We don't have imaging studies that we can use to diagnose.

And so that line ultimately that you're asking about between order and disorder, function

and dysfunction, it's operational at the moment.

How are things working?

Can we just like linger on the terms for a second?

So this disease, dysfunction, how careful should we be using those words?

Can we just, even in this conversation, from a sort of technical perspective, but also

human perspective, how quick should we be in saying that schizophrenia, depression,

autism, as we kind of go down across the spectrum of different maladies, just to use the word

dysfunction and disease?

I would say to give ourselves a license to capture the whole spectrum, let's say disorder,

because that captures truly, I think, the essence of it, which is we need to talk about

it when it's not working, when there's disorder.

And that's the fairest and most inclusive term to use.

So is it fair to assume that basically every member of the human species suffers from a

large number of disorders then?

Well, we just have to pick which ones are debilitating for each person.

If you look at the numbers, if you look at how our mental health disorders are currently

defined, you can look at population prevalence values for all these disorders.

And you can come up with estimates that somebody will have a lifetime prevalence of having

a psychiatric disorder that approaches 25% or so.

And in some studies, it could be more, some studies, it could be less.

Now, what do we do with that number?

What does that mean?

And in some ways, that's the essence of what I was hoping to approach with the book is to

reflect on this spectrum that exists for all the disorders.

There is taking nothing away from the severity and the suffering that comes at the extreme

end of these illnesses, but nearly every one of them exists on a spectrum of severity,

from nearly functional to completely dysfunctional, life threatening, and even fatal.

And so that number 25%, more or less, it doesn't capture that spectrum of severity.

Looking at that number, where do those numbers come from?

Is it self report?

Is it people who show up and say, I need help?

Is it somebody else that points out that person needs help?

Or is it like estimates that even go beyond that for people who don't ask for help or

are suffering quietly alone?

When you look at self report numbers, then those numbers get even higher, beyond 25% or

more.

The most rigorous studies are done with structured psychiatric interviews where people who are

trained in eliciting symptoms carefully do complete psychiatric inventories of individuals.

And these are time consuming, laborious studies that not often repeated.

When they're done, they're done well.

But very often you'll see a report or something in the news of a very high number for some

disorder or symptom, and very often, if it's shockingly high, that's coming from a self

report of a person.

And so that's another issue that we have, again, take nothing away from the severity

and reality and biological nature of these disorders, which are very genetic.

We understand that these are very biological, and yet we lack right now the lab tests and

the blood draws to make the diagnoses.

But we'll talk about it, just how biological they are, because that too is a mystery.

In terms of from a perspective of how to probe into the disease, how to understand it, how

to help it, so some of it could be neurobiological, some of it could be just the dance of human

emotion and interaction.

Is love when it works and is love when it breaks down, biological, or is it something

else?

We're going to talk about it, but let me just linger in terms of disorder.

What about genius?

That cliche saying like the madness and genius that they dance together.

What about if the thing we see as disorder is actually genius, unheard or misunderstood?

Here again, the numbers help us, and here's where being rigorous and quantitative actually

really helps.

If you look at disorders like autism and bipolar disorder and eating disorders, anorexia nervosa,

for example, these, particularly bipolar and anorexia, these can be fatal, they can cause

immense suffering, but they are heavily genetic, all three of these, and what's very interesting

is each one of these three is actually correlated positively, positively, with measures of intelligence,

of educational attainment, and even of income.

You look at this, severe disorders in many cases, causing quite an immense morbidity

and mortality, and yet they are positively correlated at the population level with positive

things.

Can you say the three again, autism, anorexia, and bipolar?

Bipolar disorder.

Bipolar.

What's that book?

I forgot the book name, but is intelligence a burden?

Well, people can get into trouble when they think they're smarter than they are, I will

say that.

I don't know.

Sometimes in the deepest meaning of that statement, I think ignorance is bliss.

I'm a big fan of Prince Michigan from The Idiot and Ardosh from Brother Karamazov.

It can be seen as naivety and dumbness, but I think it's a kind of deep intelligence,

maybe inability to reason about the mechanics of the world, but instead kind of feel the

world.

It seems like that's one of the paths to happiness.

There is, how much you think versus how much you feel, this comes up all the time.

In medicine, we encounter this all the time, when day after day you encounter the abyss

of suffering from patients, how much do you let yourself feel, or how much do you make

it abstract and objective and try to make it clinical.

That range, how you're able to move yourself on that spectrum is very important for survival

as a physician.

The way you protect yourself and your feelings turns out to be very important.

You quote Finnegan's Wake, Mad Props for that James Joyce book.

It's like a class on James Joyce in college.

I think I read parts of Finnegan Wake.

It might have been on drugs or some kind.

I somehow got an A in that class, which probably refers to some kind of curve where nobody

understood anything.

The only thing I understood and really enjoyed is his short stories, The Dead.

And then Ulysses, I think read a few Cliff Notes that got to the point, and then Finnegan's

Wake was just a hopeless person.

For people who haven't looked at it, maybe you can elucidate to me better, but I felt

like I was reading things, words, and the words made sense, like standing next to each

other.

But when you read for a while, you realize you didn't actually understand anything that

was said.

Right.

But did you have a feeling though?

That's one thing I found interesting about Finnegan's Wake.

I never fully understood it, but the words caused feelings in me, which I found fascinating.

And sometimes I couldn't predict it from the semantic black and white context of what I

was seeing in front of me on the page, but the rhythm or the melody would make me feel

certain ways.

And that was what I always was intrigued by with Joyce.

Of course, he existed on a spectrum too, and he wrote, as you say, more accessible

works.

I learned a lot about Irish history from a portrait of the artist as a young man, and

there was just, he could be as objective as he wanted to be, but then when he let himself

loose, he was in this realm where the words had their own purpose separate from semantic

meaning from their dry dictionary definition.

There's a funny story that I was told, doesn't matter if it's true or not, but they said

that James Joyce, when he was young, when he was in his teen years would go around sort

of Ireland drinking and so on and telling everybody that he's going to be one of, if

not the greatest writers of the 20th century, and he turned out to be that.

So I always think about that little story that somebody told me, because I have a lot

of people come up to me, including myself, I'm a bit of a dreamer, and you get into certain

moods where you say, I'm going to be the greatest anything ever.

You get people tell you this, especially young people, and it kind of, it makes me feel all

kinds of ways, but that story reminds me that you just might be one of the greatest writers

of the 21st century, for example, if somebody were to tell me that, and don't immediately

disregard that, because one of the people that say that, that's almost like a precondition,

that's a good requirement just to believe in yourself.

Maybe it's not a full requirement, but it's an interesting story.

Well, I think when someone tells you that, then it creates one season opportunity, and

then it would be a tragedy if the opportunity weren't captured, right?

And so then that creates some impetus, some motivation to do something good.

I think the mind, it's like, you know, I guess that's what like books like the books or whatever,

I don't even know if it's a book, the secret plugs into, they kind of make a whole industry

out of it, but there is something about the mind believing something, making it a reality.

It is just time and time again with Steve Jobs, like your belief in yourself, your belief

in an idea, sort of embracing the me versus the world, embracing the madness of this idea

and making it a life pursuit, somehow more reality for some tiny fraction of the population.

For everybody else, you descend into all the beautiful ways that failure materializes in

our lifetime.

You mentioned love earlier.

I mean, that's a great example of how belief in something makes it real, right?

It's not reasonable on the face of it, but because you believe it's reasonable, then

it actually does become reasonable, and then it is real, and so that's a good example.

That doesn't happen.

I'm also in a bioengineering department.

We don't imagine that a bridge is soundly built, and then it is soundly built.

That's something that, it doesn't come up in too many realms of human existence, but

love is one of them, and the ability to have a fixed idea and to say it's true, and then

it is true.

A bridge is a kind of manifestation of love, so maybe it does work a little bit, but it

can break down like Chernobyl did.

You can't just say it's safe.

You have to also prove it's safe.

But on Finnegan's Wake, I think, maybe correct me if I'm wrong, you're using kind of Finnegan's

Wake to give one perspective on what madness is, of what's going on in the mind.

How much of that is that we're simply unable to communicate with the person on the other

side of their mind?

There's almost like a little person inside the brain, and they have some circuitry that's

used to communicate emotion, communicate ideas to the outside world, and there's something

about that circuitry that makes it difficult to communicate with the little person on the

other side.

If you look at what shows up in schizophrenia, with many cases, what we call thought disorders,

what we call the individual speech symptoms of schizophrenia, Finnegan's Wake is loaded

with them, and it's just full of them.

We talk about clang associations in schizophrenia where the word that is said echoes in some

way the previous word, and we call that a clang association because there's no other reason

than the similarity of the sound, like a clang of a garage door being hit, and sometimes

it's not even a word, and we call that a neologism, a new word being created, and of course Finnegan's

Wake is full of that, and then we also, in schizophrenia, what we call loose associations

or tangential thought processes, of course full of that where things just go off in

directions that are not linear or logical.

You can't read Finnegan's Wake I think without, certainly as a psychiatrist you can't read

it without thinking about schizophrenia, and then when we look at the families of people

with schizophrenia, and Joyce was no exception, there very often are people within the family

who are on the spectrum, some have it, some are able to see it from a distance, from a

safe distance, there's an association between schizophrenia and what we call schizotypal

personality disorder where people are not quite in this severe state of schizophrenia

but have some magical thinking, have some unusual thought patterns, very often those

are family members of people with schizophrenia.

So this points again to this idea that there is a range even along this very severe, very

genetic biological illness that human beings dwell on different spots along that spectrum.

I should mention that we have my friend Sergei pulling up stuff, young Sergei or old Sergei,

I don't know what to call you, but there's drafts of Finnegan's Wake, yeah I actually

saw pictures of this from, I think it was on Instagram or something, these are early

drafts of Finnegan's Wake, and it's so beautiful to see, for people who are just listening,

there's just random paragraphs and writing all over the page with stuff crossed out

and it's great to see that Joyce himself was thinking in this kind of way as you're putting

it together.

How much do you think he was thinking about schizophrenia, the schizophrenic mind?

I think a lot.

I think it's known that his daughter suffered from schizophrenia and what's depicted here

on the page is something that I'm sure he either felt himself in some level was able

to access this nonlinearity of processing or had seen enough in family that he knew

what it was and was able to reflect it down in black and white on the paper.

What he was able to do was quite authentic in that sense.

Of course, I don't want to pigeonhole him, he was doing much more than that, it was much

more than talking about altered human thought processes and thought disorders, but that

was an aspect that he was so good at representing that it had to be intentional to some extent.

A tiny tangent, what does your own writing look like for this book because it's extremely

well written?

How many edits did you just drink some whiskey and like I'm imagining Hemingway style, what's

a very different, the writing is very different, I mean, it's really, really well written,

which was like, I was reading it, it makes you realize, because I was expecting sort

of a science kind of, which it is like, you know, elucidating something about the human

mind kind of thing, but you could also probably write really strong like novels.

So maybe that's in the future, but anyway, what is your, how many edits, how many, what's

your style?

Does it look like that?

Is it more structured, organized?

Unfortunately, I used a laptop, so I didn't have this sort of a beautiful record of it.

No typewriter, cigarette and whiskey.

I did explore, which was their particular altered state that would help me to be most

creative and I found actually, I actually did the best while sober, but slightly disinhibited

in the late hours of the night or early morning, particularly late hours of the night there.

And I have a friend who would tell me that she thought that very early in the morning,

her inner critic was still asleep and she could write more effectively before her inner

critic woke up.

Yeah.

And I actually found that outstanding advice for me that I often found that there was, I

was looser and could write more in the morning.

But the other interesting thing is each chapter, each story, it's about a different human being

with a different class of psychiatric disorder, that's what each story, each chapter is anchored

in.

But I'm trying to use words and style of writing and, you know, diction that captures the feeling

of the disorder.

And so it's different in each story.

In the story about mania, which is a very expansive, exuberant, at least briefly uplifting

state where the words come out in a torrent and they're complex and pressured and elaborate,

I try to capture that feeling with the words used in that chapter.

And then in the schizophrenia or psychosis chapter where things slowly fragment over

time and become looser and separated, I try to capture that in the writing too.

So for each, it wasn't as if there was a single mode I could be in for the whole book.

For each chapter, I had to put myself into a different mode to capture that inner feeling

of the disorder.

When you put yourself in that mode, does that change you?

Yeah.

I couldn't turn it on and off right away.

I had to, first, I would start by thinking about the person or the people, one or two

people based on real patients and the stories that are put forth, the symptom descriptions

are real.

They're from the patients.

Of course, all details change to protect privacy, but the actual symptom descriptions

are real.

And I would sit with them and really try to inhabit the space of the mind of that person

that I knew.

And that's not instantaneous, it would take some time.

I needed quiet.

I needed to be still.

That's another reason late at night is good.

Sergei posted that draws in his gifts, creativity boosts according to Andrew Huberman.

Thank you, Andrew.

He's not wrong.

He's not wrong.

Why projections?

Is it, I mean, instead of putting words into your mouth, because I can imagine a lot.

To me, I will start putting words in your mouth, despite what I just said.

So to me, projections, working on neural networks, for example, from an artificial neural networks

from a machine learning perspective, it's often, that's exactly what you're doing.

You're having an incredibly complex thing and you're trying to find simple representations

in order for you to make sense of it.

So I was kind of thinking about in that way, which is like this incredibly complex neural

neural network that is kind of projecting itself onto the world through this low bandwidth

expression of emotion and speech and all that kind of stuff.

And the way it's, we only have that window into your soul, the eyes and the speech and

so on.

So in that way, when there's any kind of disorder, we get to only see that disorder through that

narrow window as opposed to the full complexity of its origins.

The word projections definitely serves that purpose here, but it's got a few other really

appropriate, other connotations as well.

So the first thing is a projection in terms of neuroscience is this long range connection

that goes from one part of the brain to another.

And so it's what binds two parts of our brain together.

There are projections, long range connections of axons.

These are the outgoing threads that connect one part of the brain to another part.

There's a projection that links, for example, auditory cortex where we hear things to reward

centers where we can feel, where feelings of pleasure and reward are initiated.

And it's been shown that if you have reduced connectivity along that dimension, you are

less able to enjoy music.

And so these connections, these projections matter.

They define how effectively two parts of the brain can engage with each other and join

together to form a joint representation of something.

So that's one meaning.

It's pure neuroscience.

The word projection is used all the time, and it happens to be something that optogenetics,

a technique that maybe we'll talk about a little later, works particularly well with.

We can use light to turn on or off the activity along these projections from one spot of the

brain to another.

And this is particularly referring to the long range connections?

Yeah, it's particularly straightforward along these long range projections that connect

different parts of the brain.

But it works over a shorter range, too.

But then there's this other meaning of projections, which you were bringing up, which is very

relevant, which is at some point you can reduce something from one level of dimensionality

to another, and you can project down into a lower dimensional space, for example.

And then finally, there's a psychiatric term projections, which comes up all the time,

which is we very often will look at our internal states and to understand somebody else, we'll

project them onto somebody else, we'll try to understand someone else's behavior and

make sense of it by projecting our own inner feelings, our own sort of narrative onto them

and use that as a way to help us understand them better.

And we'll do the reverse, too.

We'll take things we see in the outside world and we'll bring them into ourselves and see

how well they map, how well they align.

That's called introjection.

So projections turns out to be a really rich word.

And finally, of course, there's the very common sense of it as a projector that illuminates

by conveying information across space with light.

So for English, for English language, perfect word to use for this book, but what's funny

is not every, there are a lot of international translations now, and all those rich connotations

aren't captured in other languages.

And so for some translations, connections is used instead of projections.

In fact, even in England, the British version is connections instead of projections because

apparently, projections doesn't have the full connotation I was told there.

So you have to sacrifice some of the rich ambiguity of meaning with connections.

That's interesting.

I mean, words are so interesting, they have so many meanings.

I love language and how much is lost in translation.

I'm very fortunate enough to be able to speak, I'm not good at languages.

I was just, I guess, forced to, by less circumstance, to learn two languages, Russian and English.

And it's just so interesting to watch how much of culture, how much of people, how much

of history is lost in translation.

The poetry, the music, the history, the pain, the way the scientists actually express themselves,

which is funny.

I mean, just, it's so sad to see how much brilliant work that was written in Russian.

There's a whole culture of science in the Soviet Union that is not lost.

It makes me wonder in the modern day, how much incredible science is going on in China

that is lost in translation.

And I'll never, I mean, that makes me very sad because I'll never learn Chinese in the

same way that I've learned English and Russian.

Maybe whenever I say stuff like that, people are like, well, there's still time.

You know, yeah, that's actually fair.

That I think the 21st century, both China and US will have very important roles in the

scientific development, and we should actually bridge the gap through language.

And that doesn't just mean convincing Chinese to speak English.

That means also learning Chinese.

Well, we need these bridge people who can do both, you know, Nabokov, for example, writing

in English beautifully, you know, one of my favorite poets, Borges, who, you know, mentioned

earlier, he wrote both in English and in Spanish, I think, you know, beautifully in both.

We need those people who can serve as bridges across cultures who really can do both.

You mentioned Borges.

So you opened your book with a few lines from a poem by Jorge Luiz Borges, a love poem.

I'm going to read parts of it because it's a damn good poem.

Yeah.

It's called Two English Poems.

I mean, there's, I'd like to understand why you used it and the specific parts you used,

which is interesting.

But then when I read the full thing, so I think you used it as a sort of beautiful description

of what it means to delve deep into understanding, offering yourself to the task of understanding

another human being.

But if you look at the full context of the poem, it's also a damn good description of

being hit by love and overtaken by it and sort of trying to figure out how to make sense

of the world now that you've been stricken by it.

It says a bunch of things about chatting and significantly with friends and all those kinds

of things.

And then the poem reads, the big wave brought you.

This is the moment, I guess, of the universe where the two people you fall in love.

Maybe I'm totally misreading this poem, by the way.

It doesn't matter.

You can't misread the poem.

So it goes on, words, any words, your laughter, and you so lazily and incessantly beautiful,

we talked and you have forgotten the words.

The shattering dawn finds me in a deserted street of my city, your profile turned away,

the sounds that go to make your name, the lilt of your laughter.

These are the illustrious toys you have left me.

So these little memories of these peculiar little details, he remembers, those are the

illustrious toys.

I apologize to mix my own words with the poem, but you should definitely read it.

I turn them over in the dawn, I lose them, I find them, I tell them to the few stray

dogs and to the few stray stars of the dawn.

Your dark, rich life, I must get at you somehow.

I put away those illustrious toys you have left me.

I want your hidden look, your real smile, that lonely mocking smile your cool mirror

knows.

I want your hidden look, your real smile.

So this is the first part of the poem, and then it goes on, which is some of the parts

that you reference.

Second part is, what can I hold you with?

I offer you lean streets, desperate sunsets, the moon or the jagged suburbs.

I offer you the bitterness of a man who has looked long and long at a lonely moon.

I offer you my ancestors, my dead men, the ghosts that living men have honored in bronze.

My father's father killed in the frontier of Buenos Aires, two bullets through his lungs

and so on and so on.

I offer you whatever insights my books may hold, whatever manliness of humor my life.

I offer you the loyalty of a man who has never been loyal.

I offer you that kernel of myself that have saved somehow the central heart that deals

not in words, traffics, not with dreams and is untouched by time, my joy and adversities.

And I think this is where the part they include in the book.

I offer you the memory of a yellow rose seen as sunset, years before you were born.

Damn, that's a good line, okay.

I offer you explanations of yourself.

Stories about yourself, authentic and surprising news of yourself.

I can give you my loneliness, my darkness, the hunger of my heart.

I'm trying to bribe you with uncertainty, with danger, with defeat.

That is a man who's in love and longing, but I just want to go back to, maybe you could

say why you wanted to include that poem, but also your dark rich life, I must get at you

somehow.

I put away those illustrious toys you have left me at.

I want your hidden look, your real smile, that lonely mocking smile, your cool mirror

nose.

Well, sometimes I meet a stranger and I just, it's like a double take.

It's like, who are you?

Have we met before somewhere?

Who's that person behind there?

And I want to get at that, whatever that is.

And of course, maybe that's what love is because maybe that's the whole pursuit, like a lifelong

pursuit of getting at that person.

Maybe that's what that is and like that insatiable sort of curiosity to keep getting to it.

Like, well, who's that person in your private life?

Yeah.

So that, absolutely, I think that it was a beautiful description of what you just said

when there's that first moment and then you want to dive deeper.

You want to know what the hidden mysteries are.

In a way, it's a love poem.

As a scientist though, it's also, it's a bit of how a scientist can love science.

And that wanting to dive deeper is, it's almost like, again, where the, it could be a love

affair with investigating the human mind, for example.

And that was one reason it spoke to me also, again, thinking about the broader sweep of

where the human mind came from, the steps it took to get where it is today, what was

given up along the way, what compromises were made.

And here's where the darkness of the poem starts to come in a little bit too.

It doesn't shy away from the negativity, from the confusion, from the danger.

And then at the very end, the Board of Haces is offering up scenes from his life, parts

of himself.

And this is how we connect with people.

We offer up parts of ourselves.

Just here it is.

And then we see how well does that map onto what you have.

And it's that offering up that I liked and not the good stuff or not only the good stuff.

The yellow rose is nice, but he's offering up the bad stuff too.

And that to me was important for the book because I'm offering up hard stuff too, in

fact, a lot of it.

And also, hard stuff from within me, from my own personal side too.

And that was, there's a lot of vulnerability that comes with that, but that's, that comes

with love, that comes with writing, you have to be open, you have to be vulnerable.

And so, I thought that reflected what I was trying to do and I thought it was as an epigraphic

kind of made it clear how vulnerable I was in taking the step, but also what could come

out of it.

And also, in a meta way, because I was not familiar with this poem, it may be curious

of the poem itself to pull at that thread of finding out more.

You picked a very particular part that kind of means you want to pull at that thread and

see where did this, where did these few lines come from?

Because I read it as a curiosity of a scientist, those lines alone.

And also, as a desperate human being, searching, like offering himself for an understanding

or connection with another human being.

And then, because I wasn't sure if it's a love poem or not, or if it's desperation

or if it's curiosity, whatever it is, and then you see the love poem.

I mean, I don't know, that's going to stick with me for a while, your dark, rich life.

And then a few lines in here are just, I mean, those are, I'm going to just use them

as pick up lines at a bar, I offer you the memory of a yellow rose seen at sunset years

before you were born.

Now, that's a pick up line if I've ever heard one.

Anyway, sorry.

But this is universal.

You see it in so many forms of art, like we're in Texas now, you see this in country, country

and western songs, it's often a list of things, like here's how I describe myself, there's

this and there's that, and there's the other thing, and here you are.

These things matter to me, and I hope they matter to you too.

It's a pretty universal form, but he did it in this very artful and very vulnerable way.

It was both beautiful and you could feel the hurt coming from him too, and that was important.

And the dark stuff too, I offer you my ancestors, my dead men, the ghosts that living men have

honored in bronze and talking about two bullets through his lungs, bearded and dead, wrapped

by his soldiers in the height of a cow, my mother's grandfather just 24, heading a charge

of 300 men in Peru, now ghosts on vanished horses.

So all of it, the whole history of it.

Because it is a love poem, what do you think about love, Carl?

What's the role of love in the human condition?

We'll talk about the dark stuff, but maybe love is the dark stuff too.

I mean, it's the most powerful connection we can form, and that's what makes it so important

to us.

It's the strongest and most stable connection that we can form with another person, and

that matters immensely, it matters for the human family to have evolved to be something

that could survive against the odds that we've faced over the years, that unreasonable bond

that becomes reasonable by virtue of its own existence.

And of course, that joy, the wild, raw joy of love is not a bad thing either.

But you put these together, the strongest bridge we can form, and the reward and the

joy that it brings, that's what love is to me.

And from my perspective, this is something that, it can be hard to capture fairly because

you want to talk about the positive and the negative sides at once.

They need to be wrapped up together for a full, honest description of what it is.

And that's hard to do in a compact form.

And so, you have to take time to talk about love, you have to take time to do it justice.

It takes a book or at least a poem or several thousands of them.

I don't know, could you pull up, there's a video I saw, yeah, like right here.

So can you pause for a second?

So there's March of the Penguins.

So you always see like penguins huddling together against, I mean, sorry if I see just metaphors

and everything, but them huddling together against the harshness of the conditions around

them.

That's very kind of, that's like a metaphor for life, like finding this connection.

That's kind of what love is, it's like it allows you to forget whatever the absurdity,

whatever the suffering of life is together, you get to like huddle for warmth.

And that's why I love the sort of just the honesty and the intensity of the way penguins

just in the middle of like the cold do this.

And then this video I saw a lonely, this is misinformation.

So the name of the video is Lonely Deranged Penguin.

I don't know if he's deranged.

So if you play it, so he left his pack and there's a nice like voiceover and you don't

need to play it, but he for some reason left the pack and journeyed out into the mountains.

And so the narrator says that he's deranged, he's lost his mind.

Now I'd like to project the idea that he's actually, there's so many stories you could

think of.

He's returning to his homeland.

He's an outsider thinking, journey out into the unknown thinking he may be able to discover

something greater than the tribe.

He might be looking for lost love.

Why is he deranged immediately?

Why is he lost his mind anyway?

But people should look up this video because to me, I might be the only one who romanticizes

this, but it's such a nice kind of, it's both a picture of perhaps a mental disorder, which

is what the video kind of describes.

And it may be some deeper explanation that's not, that has to do with the motivation of

a mind.

Yeah, I don't know if, I don't know if you have a deeper analysis on this, Penguin.

Well, I, like you, psychiatrist, I would, I would want to sit down with a penguin and

go through, I want to see the notes from his prior therapist.

But this, this actually is relevant.

Not knowing what was that penguins motivation.

We have very clear situations where there are both within an individual, we go through

periods of time when we stay in one place and we reap the benefits from what we've built.

And then we go through periods of foraging, of wandering, even if there may be resources

where we are.

We have periods of time in our lives where we wander, where we go in an exploratory mode.

And different people express that trait in different ways.

This is not a human specific trait, if you go down to, to the tiny little nematode worm,

sea elegans with 302 nervous system cells, they go through these phases of foraging and

rest and different individuals have different propensity to forage or, or to rest and stay

in one place.

At the level of the species, that's really good that there's that diversity in their

willingness to forge.

Some stay where they are, the species is somewhat on a firm footing then.

But some carry a burden, a risk for themselves, but it's good for the species that they're

explorers and they will venture out.

The migration patterns that different species blunder into and that turn out to be really

good.

They weren't logically derived.

They most certainly started from something like this, an exploration.

If humans do this too, you think?

And we do it too.

In fact, it's something we do extremely well.

Let's talk about psychiatry a little bit.

So in my book, you're a rock star.

First of all, for people who don't know, you're one, aside from sort of the neurological

view of the brain and neuroscience view of the brain, you're also one of the great psychiatrists

of our time.

I've always, not always, but when I was younger, I dreamed about being a psychiatrist.

So it's like getting to meet your heroes and also getting to meet the people who the best

at the top of the world at the thing you've failed to pursue.

So I'm getting a free therapy session on top of that.

So what big picture, what is the practice to go the hope of modern psychiatry?

If you could try to describe the discipline as you see it, maybe historically throughout

the 20th century in contrasting to what it is today, or maybe if you want to describe

to what you hope psychiatry becomes or longs to become in the 21st century.

It's been an interesting journey.

Psychiatry started out pretty firmly grounded in neurology and pathology.

Only initial founders effectively of the field were very well grounded in microscopy, looking

at cells, working with patients, particularly on the neurological side, and this certainly

included Freud and some of his contemporaries.

But they rapidly discovered that what they could work with at the level of cells and

microscopy was so far from the realm of what they could get from a human being and what

they were getting from the human being was so much more interesting and had so mysterious

and so unknown that many of them just said, we're going to inhabit this domain and we're

going to work with the people, with their words and understand what we can based on

verbal communication because that was the only tool that people really had.

And that was a very important step for the field.

I would say one of the interesting things that came from the early decades of psychiatry

really was this distinction between the conscious and the unconscious mind and paying particular

attention to the unconscious mind as something that was worthy of consideration that might

be important in explaining people's actions and that perhaps even insight into that was

valuable in its own right.

And out of that psychoanalysis became a practice that was not always focused on cures or treatment

but was more focused on insight.

What does it mean?

How can we help people understand why they're feeling something or thinking something or

dreaming something?

And that insight separate even from treatment was an interesting thing as long as one was

honest about that and said, we're going for understanding, we're going for insight.

Maybe it's useful to just pause on that.

If you look at the father of psychoanalysis, Zygmunt Freud, what do you make of the ideas

that he had?

So you mentioned taking the unconscious, the subconscious seriously.

That's like step one, like that there could be worlds we do not have direct access for

and we probe at them through conversation or is that too simplistic to call psychoanalysis

conversation?

That's not too simplistic.

But that's right.

And I think that was valuable where Freud ended up breaking from some of his contemporaries.

He was very focused on this unconscious as being so tightly linked to libido.

And really, from his perspective, you couldn't really separate the operation of the unconscious

mind from these aspects, the libidinous aspects and that was one reason, sexual related drives.

Carl Jung, who was contemporary, that's one factor that led to them separating was Carl

Jung felt there was a lot more to the unconscious than this libidinous aspect of it.

And he saw it as a much more complete alternate representation of the conscious self, one

that maybe reflected a whole range of different motivations and desires and to properly treat

it when had to consider all of them rather than the ones that that Freud was hooked on.

Yes, Carl Jung, thank you for the high level of images that Sergei is pulling up for people

who are just listening.

He pulled up as a quote from Sigmund Freud's meme, your mom quote, Freud.

So the shadow, the Carl Jung shadow encompasses everything, not just the desire to have sex

with your mother or sex period.

If you look at those two folks en masse, I mean, there's a kind of, it's almost like

a technique for philosophical exploration of human mind, human motivations.

So it's not even necessarily, it's also doubles as a methodology for helping people, but it's

almost like a, it's a kind of philosophical method.

Right.

This is the fascinating thing about psychoanalysis and even though it's, I would say, mostly

not considered a treatment today, it persists for a couple of reasons.

One is, it's thought that it gives people some insight.

But second, there's been a huge influence on literature, on philosophy, on art.

And the opening up of discussion about what was below our conscious mind was so fertile

in the implications that it sort of reverberated and still does throughout all these different

realms of human endeavor from different artistic experiences that people have can be colored

by this concept of the unconscious.

Now the other thing that was interesting is this distinction, what are the parts of the

unconscious?

And so there were these id and ego and superego subdivisions that Freud, for example, would

talk about them.

And the id was the primary, the primal drives that an infant would have or that a very young

child just warmth and feeding and then later the sexual or libidinous aspects.

And for Freud, the later happened very quickly.

Just the controversial thing about him, I think, I guess he thought even children had

sexual desires that they're dealing with, contending with.

So it's the full thing, hungry, wanting to eat, wanting to poop, wanting to have sex.

And he was extremely focused on that aspect.

But then there was the superego which brought on these later sort of moralistic sort of codes

of conduct.

And that, of course, was very often intention, but all this could play out subconsciously.

And then the ego, this third aspect was mediating and Freud's conception mediated this tension

between the different parts.

Now I think that's interesting.

I will say that in some ways it's maybe unnecessary from the perspective of modern neuroscience

to divide things up that way from the moralistic drives and the primal gratification drives.

In some ways they're all drives and maybe they're even all primal drives.

The moralistic drives they're taught and they're taught in ways that ultimately relate back

to survival and you could even say selfish aspects of health and life for the self and

family.

And so this is, I think it's maybe an artificial distinction.

The concept of the unconscious is very valuable and very interesting.

But these categorizations of id and superego may not map onto neurobiology in any particular

way.

If there's a town hall of competing drives and desires and they interrelate to each other,

they involve different aspects of the brain and the history of the person.

And actions and choices come out of the result of that overall shouting in the town hall.

So in some sense Carl Jung was a step into the direction of liberating yourself from

such harsh categorizations.

I mean, you have Daniel Kahneman with system one and system two, there's just these very

compelling categorizations of the human mind that seem to be sticky in the superego, how

we talk about these ideas and so on.

Do you think those are helpful or did they get in the way?

Is it some kind of balance in terms of deeper understanding of how the mind actually works?

Yes, from modern neuroscience, whenever we seem to get closer to addressing a question

like this at the level of cells, it seems to get farther away and I'll give you an example

of what I mean by that.

So one thing I'm doing in my laboratory and many people are doing is we are listening

in on the activity of cells, neurons in the brain of mice or rats or fish or monkeys.

Individual cells.

Exactly.

Of which there are in our brain many billions and when we do and we try to predict what

action will be taken by an animal to address this question, where does the choice arise?

Where does the impetus to make a particular selection of one action versus another action?

Where does that start in the brain?

If you're recording, listening in on the activity of cells all across the brain, where

is the earliest spot you can pick up a choice being made?

Well,

That's so awesome.

Yeah.

At one level, you might think how excited would a young have been to see this or Freud

or the early psychoanalyst to see where this starts, but it's not so simple because an

emerging theme in very recent neuroscience literally over the last few years is that things

sort of all start together all across the brain.

And so you can be recording from the cortex, this rim of cells at the surface of the brain,

or you can be recording deeper in a structure called the striatum, which is a little older.

It's more tightly linked to action.

And then structures called the thalamus, other parts of the brain.

And if you record from these, these all sort of represent the action and the choice more

or less all at about the same time, very close.

And so it's, you can't point to a particular spot and say, here's where the choice or the

action originates.

It's a group.

It's finding the free will neuron.

It's relevant to that question.

Nobody is close to being able to point to such a thing.

Well, close is a relative term.

And nobody, what I, what I tweet today, all generalizations are wrong.

So including this one, let's actually talk about that.

So the study of individual cells, if you can linger on your sense that as you get closer

to that understanding, it feels like you're getting farther away.

Why is that?

Cause that, that often is the feeling until you're actually there.

So, so like, you know, see that's when I'm running and I know there's only a mile left.

It just feels like that mile is just getting longer and longer.

But eventually you finish.

So maybe we're getting close to cracking open these like beginnings of a sense, like we'll

talk about consciousness or these very difficult big questions about the human mind.

Where do they start?

You're right to say we shouldn't generalize or make absolutist statements, but I would

say right now, the reason things are looking even harder to crack than we had initially

thought.

We now have the data streams that we've wanted for so long in terms of activity patterns

all across the brain at the level of cells.

We can literally see what cells are doing, immense data sets, you know, we get, these

are, you know, time series of one individual cell with, you know, sub second resolution

and you can collect this from, you know, enormous numbers of cells across the brain.

So very rich data sets that we've wanted for a long time and yet having these has not

led to an understanding of truly where actions initiate in terms of regions or locations.

I ask a few questions on that.

Is the answer high level question by your intuition?

Is the answer within the data or do we need different kind of data?

So we should also say that when you collect data about the brain, there's like the richness

of information you're collecting, but there are also human doing stuff, like, and information.

So static information about the human and dynamic information about the human.

And you can get them to do different stuff and you can select different humans.

And that's part of the collection of data aspect.

So like when you're collecting data about the brain, there's some truths that you can,

you know, machine learning is like annotations like supervised learning.

There's some true things you can hold on to before you look at the full rich mess complexity

of the human mind.

So given the data you've looked at, do you think the answer for the for the origin of

free will in the human mind can be found?

Well, one amazing thing is that nobody's found it, but we have these rich data sets.

And then there's a conundrum, which is, is it in the data, and we just don't know how

to look at it.

Maybe we don't know the right scale, the right projection to make of the data, the right

way to interpret it.

And here's where causal testing becomes very valuable, because then instead of just passively

observing, well, here are here the activity patterns, and then here's the choice made

by the animal as we've gotten more powerful at reaching in and causing things to happen

in the brain, turning up or down the activity of certain types of cells or defined populations

of cells and seeing how that affects actions.

These causal perturbations have turned out to be very valuable.

We're just now getting to the point where we can apply these in very wide swaths of

the brain at cellular resolution, and so we're going to be able hopefully to make some headway

on this question with causality.

And that's the one thing that Optogenetics provides us this way of using light that we

developed to control cells.

This is an untapped, relatively untapped at this broad brain wide scale, and hopefully

we can get there in the near future.

But I would say that the answer may be in the data, but we don't know how to find it.

Well, there's this interactive element like where you can cause stuff that's really powerful

because you get to, I mean, as opposed to collecting data passively, you're collecting

data actively.

So can you maybe describe one of the many things you're known for?

One of the big things is called Optogenetics.

What is it?

Optogenetics is a way of causing things to happen.

It's a way of determining what actually matters in terms of the activity of the brain for

the amazing things.

It does sensation, cognition, action, and what it does is it provides activity.

It's a way of playing in, if you will, activity patterns into precisely defined cells.

And the way we do it is pretty cool, I think.

Right away there's a problem.

If you think about how do we do this, how could we play in well defined activity patterns

and provide a stream of activity into this cell and that cell and that cell, but not these

other cells?

So just for context, we're talking about the brains of mice, monkeys, humans, and then

the goal is to try to control accurately the behavior of a single neuron and then to be

able to monitor single collection of single neurons to then say, well, to draw some deeper

insight about the origins, first of all, the function of different parts of the brain,

different neurons, different kinds of neurons, but also the origins of the big things, the

flap of the butterfly wing that leads to an actual behavioral thing.

So if you could, exactly.

So if you could turn on or off the brain or parts of the brain or cell types or individual

cells at the natural rate and rhythm and timing of normal brain activity, that would be immensely

valid because you could determine what actually mattered, what could cause complex things to

happen and what could prevent complex things from happening in a specific way.

But right away you've got a problem if you want to do this and neuroscientists have wanted

to do this for a long time.

Francis Crick of Double Helix of DNA fame, he wrote a famous paper in 1999.

He got interested in neuroscience later in life and he said, what we need in neuroscience

is a way that we could turn on or off the activity of individual types of neurons in

a behaving animal.

And he even said the ideal signal would be light because it would be fast, it could penetrate

through the brain to some extent.

And he had no idea how to do it, he said this would probably be very farfetched but it would

be a good thing.

And so that's what you're actually saying, like if you want to do this kind of thing

and imagine like, how do I get inside the brain?

It's pretty difficult to do.

It's pretty difficult.

And then even once you get in, it's hard because all brain cells are electrical, all neurons

are electrically activated.

And so if you wanted to use electricity as what you were putting in, you won't have any

specificity at all.

If you have an electrode, a wire and you put it in the brain and you send current through

it, all the cells near the electrode will be stimulated.

That's like trying to control fish by spraying them with water.

Yeah, right, because there's already a lot of electricity going around anyway and you're

adding more, but there's no specificity, even among the different kinds of cells either

because all around the wire that you've put in, there are going to be so many different

cells doing totally different things, many of them in opposition to each other.

We know that's one way the brain is set up.

There are parts of the brain that where neurons side by side are doing completely different

things and maybe even antagonistic to each other.

So what do you do?

How do you play in activity with any kind of specificity?

Well, what you do is use, what we found is what you can do is make some cells responsive

to light.

Now normally, no cells deep in the brain really respond to light.

They're not built for that.

There's no reason for them to respond to light in there, which is a great situation to start

with because any light sensitivity you can provide to some cells will be a huge signal

above the noise.

And so that's what we do with optogenetics, we take genes, bits of DNA from microbes,

single celled organisms and these single celled organisms like algae, they make little proteins

that sit in the surface of their cells that receive light, capture a photon of light and

open up a little hole in the membrane of the cell and let charge particles, ions like

sodium and potassium flow across the membrane of the cell.

And that, these algae and bacteria, they do this for their own reasons because that helps

them move and helps them make and use energy.

But that's a beautiful thing for neuroscience because movement of ions charge particles

across the membrane of the cell is exactly the kind of electricity that neurons work

with.

So if we can take this bit of DNA that encodes this beautiful protein that turns light into

electricity from algae and if we can put it into some neurons but not other neurons,

which we can do using genetic tricks, then you've got a situation, then you can shine

on the light and only the cells that have the gene and that are expressing the gene

will be the initial direct cells that are activated by the light.

And so that's the essence of optogenetics is the ability to do that.

We get that initial specificity that you could never get with an electrode.

First of all, let me say that this is, we recently got the Alaska Prize for this.

It's a brilliant idea.

So I talked to Andrew Huberman, who's a friend of yours, friend of mine, not to jinx things,

but he believes that you deserve the Nobel Prize for this.

So I do too, but what my votes, anyway, the thing is, it doesn't matter, prizes will

be all forgotten.

All of us will be forgotten.

One of the cool ideas, a cool idea, that's a really powerful idea.

It's actually the origins of it you might be interested in are even are very deep.

There was a botanist in St. Petersburg named Andre Femenson in 1866.

He published a paper on the single celled green algae and he was the botanist who first

noticed that they moved in response to light.

These are tiny single celled algae that have flagella, so they swim through the water.

And he noticed this, he was a botanist, and he published this, it was a paper, you know,

he wrote in German, but he published it in a French journal and he was doing it from

St. Petersburg.

So it was a very international effort, but you have to go back to 1866 and that, I like

to highlight how far back that discovery goes is back to Andre Femenson.

And this is a, it highlights the value of just pure basic science discovery.

That always originates somewhere in the Eastern European bloc.

But I don't think he expected the splicing of genetic material from the algae into the

human brain.

And one of the cool things we've been able to do now with modern methods is to really

study these proteins.

And so we've discovered some of these proteins other groups have as well.

We've dived deep into their structure, just like the double helix structure of DNA was

uncovered with Xray crystallography.

We used the same method, Xray crystallography, to see how these beautiful little proteins

work.

We reengineered them for all kinds of function.

We can make them instead of responding to blue light, we can make them respond to red

light.

We can speed them up, slow them down.

We can make them with genetic engineering, we can make them have different ions flow

through them.

And so it's this convergence, as you said, like the botanist in 1866 couldn't have predicted

what we could do with this, and the fact that we've been able to discover how these beautiful

proteins work and then apply them to neuroscience is really a thrilling story.

Is it possible to achieve scale, do you think, with this, meaning like what is the progress

of the next 50 years, 100 years looks like, in terms of the precision and the scale of

control of using light?

It's going so fast, it's hard to predict.

I'll give you a sense of it, though, in first paper, we published in 2005, that was just

in cultured neurons, by 2007, so that was in a dish, by 2007 we had it working in behaving

mice, by 2009 we had it pretty general, so we had methods to really make it a versatile

method, it could be applied to essentially any cell.

By 2012, we could get to single cell resolution, we used light guidance strategies to target

individual cells in the brain of a living mouse.

By 2019, we were able to control up to 20 to 50 individually specified single cells

in the brain of a mouse in ways that specifically changed its behavior, that could bias its

decisions one way or the other.

In fact, we could take a mouse and without any visual stimulus at all, we could make

it act as if it had seen a particular visual stimulus by playing in, using the single cell

resolution optogenetics, a specific pattern of activity into 20 or 25 individually specified

cells.

That's 2019, to your question of scale, now in 2022 we're controlling hundreds of individually

specified single cells over all of visual cortex of a mouse, all the part of the brain

that is the initial direct target of the incoming information from the retina.

Are you constrained to specific types of cells currently?

Like you mentioned long range is easier, is there constraints on which cells?

Now there really isn't, now that we have this individual cell guidance, we can target any

individual kind of cell very reliably, and so now to your question of scale, how far

can we go?

Well, things are moving quickly, it's hard to say.

We can access individual cells across the entire brain now.

If you look 10, 20 years in the future, I think we'll surprise ourselves, but the fact

that we're already able to cause specific perceptions to happen in specific actions

means we're essentially where we want to be, and now it's a matter of just more experiments,

more discoveries, but the basic principles are clear now.

The basic capability is there.

Is there a pathway to doing the same for humans?

Optogenetics is primarily, it's a discovery tool that really is well suited for use in

mice and rats and monkeys, because it involves putting in a gene and also delivering light,

and those are two things that you can do in human beings, but you'd want to do in a very

careful way.

Now, that said, there is actually just less than a year ago, my friend Botan Roska in

Switzerland, he did the first human optogenetics therapy, and he published this in the journal

Nature Medicine.

So about 10, 12 years ago, he and I published a paper together where we gave him one of

our optogenetic tools, one of these light activated regulators of ion flow, these are

called microbial opcins, by the way, opcins, and he put one of those into an extracted

retina from a human being who had died, so it was a cataviric retina, and he was able

to show that optical control in this paper was able to turn on or off individual cells

in the human retina.

So that was a while back.

He spent about 10 years of going through all the regulatory hoops and hurdles and going

through primate studies, and finally he was able to take a human being with a retinal

degeneration syndrome, so someone who was blind in both eyes.

And he gave one of these opcins into one eye of this human being who was blind and with

the goal of conferring light sensitivity onto this retina that was not able to see light,

and he was able to make this person see through that eye.

So he took a blind person and the blind person could see now, could reach for objects selectively

on a table, and he published this in Nature Medicine, and it was, you know, that's an

amazing thing.

Do you know the title of the paper?

What's his name again?

Rosca.

R.O.S.K.A.

Can you look up the nature paper?

Yeah, Nature Medicine.

Nature Medicine.

So that's sort of proof of principle.

Now the retina is very accessible.

It's near the surface.

You can use natural light or you can use brighter natural light.

I'm, myself, I see optogenetics as a discovery tool.

It's a way to figure out the principles by which the brain works and how it operates.

Partial recovery, visual function in a blind patient after optogenetic therapy.

So he went through the full process of doing primates, studies, and then going, well, that's

dedication and that's really exciting to see.

As beautiful as that is, and I'm glad he did all that work, there are so many other ways

that optogenetics could help with therapies.

Once you know the principles, then any kind of therapy can become more powerful.

Once you know the causal cells in a symptom like in lack of motivation or inability to

enjoy things or altered sleep or altered energy.

Once you know the cells that are causal, then you can make medications that address those

cells.

You could address brain stimulation treatments that might address those cells.

Also diagnosis, maybe a very effective systematic way of diagnosing, or at least providing you

rich data to some of these deep questions about schizophrenia, about bipolar, all those

kinds of things that are, the tools are low resolution currently for determining the degree

to which you have a thing and whether you have a thing at all.

Yeah.

Exactly.

So my hope is, that's a great example of how you can cure or you can provide some relief

for a symptom of a person who has a serious degenerative disease.

But the principles are what we're after.

That's why I spend, even though I'm a psychiatrist, even though I still see patients, I'm not

myself trying to drive any clinical trials in the lab.

I'm trying to discover and then any kind of therapy could result from that.

What do you think about my friend Elon Musk and his efforts with Neuralink?

So this is another, there's a lot of things to say here because there's a lot of ideas

under the umbrella of Neuralink, but one of them is to use electrical signals to stimulate

and then you also record, you collect electrical signals from the brain at a higher and higher

resolution and you go implant surgically the methods by which you do the stimulation

and the data collection.

So it's possible for the ideas of optogenetics to play well with this and we can even zoom

out outside of just Neuralink and just the whole idea of brain computer interfaces.

What are your thoughts?

Well, I think the engineering that they've done is actually pretty cool.

So I like the robots, from the design perspective and it was a design approach that wasn't being

taken in academia and it's great that they did it and I think it's pretty cool.

So I'll say that.

Also there are many ways that you can record from many thousands of neurons and that's

not the only way.

It's a very interesting way.

We and others are using brain penetrating electrodes that actually get quite deep.

The whole structure of the brain is very interesting.

There's the surface cortex where it's the most recently emergent part of the brain

and evolution.

Mammals have it.

Reptiles have something a little bit like it, but it's not really the whole thing.

This is a very recent thing.

That's what we can access with some of these, like the Neuralink approach and with some

of these short electrodes.

This part of the brain in the cortex is only a few millimeters thick.

There's so much that's deep though that's so important.

There's the striatum.

There's the thalamus.

There are the parts of the brain that drive motivation, that drive hunger and thirst and

social interaction and parenting and flight and fear and anxiety.

All these things are, there's so much that's deep that these surface approaches are not

getting to.

Some are deep and others are using these very long electrodes that help us get deep.

We can still record for many cells, many thousands of cells.

We can have multiple of these at once in the same animal.

There's a diversity of methods to get to this goal.

I think it's great that people coming from outside academia will bring ideas that weren't

being worked on, at least approaches.

They may turn out to be synergistic.

These things do work very well with optogenetics because all these electrical recording methods,

that's one channel of information flow.

Light delivery is a separate, more or less independent.

There can be some artifacts that happen, but if you're careful, that's another independent

pathway of information flow.

We've done really fun experiments in mice where we play in patterns of activity with

light and we record activity from all across the brain of a mouse, electrically.

Using optical and electrical together is extremely powerful.

Optoelectric brain computer interfaces, which, by the way, there's efforts on the computing

side to build optoelectric servers where you have both electricity.

Optics is really interesting.

Light is a very interesting method of communication that's, like you said, orthogonal in many

ways.

It doesn't have some of the constraints of bandwidth that electricity does go into wires,

but you're able to, but it's less ability to control precisely at scale.

There's challenges and there's benefits and having those two interplays is really, really

fascinating, especially when, obviously, on the other side of your signal is a biological

mesh, mush, mushy mesh.

The mushy mesh is kind of interesting because there are problems with light.

Light scatters in the brain, so the photons don't just go linearly through.

Whenever they hit an interface between fat and water, lipid and water, they bounce off

in different directions.

You can come in with all the resolution you want.

You could play in an incredibly detailed high resolution pattern of light, but the photons

start scattering quite quickly and by the time you've gone a couple of millimeters deep,

you've lost almost all that fine spatial information.

But we've developed workarounds.

The longer wavelength light you use, if you get into the infrared, there's less scattering.

You can use two photon methods or three photon methods where the photons have to arrive all

together at the same time.

You can put in fiber optics.

We developed these fiber optic methods in 2007 where you can access these deep structures

with fiber optic methods and you can put in many of these fiber optics at the same time

in an animal.

We've used holographic methods, 3D holograms to play in, hundreds of individual cell sized

spots of light and we can change those quickly.

So there are a lot of tricks, a lot of interesting optics engineering that has come together with

neuroscience in a pretty exciting way.

Oh, it is engineering too, which is super, super, super exciting.

I should mention, because I remember, I mentioned Elon.

I recently got, for the first time ever, got COVID.

How did I go so long without the, finally, so I'm all vaccinated and everything like

that.

And so I got, because I think he mentioned it publicly so I can mention it, but I won't

mention anybody else involved, but hanging out, we all got, you know, I got COVID.

And the interesting thing about, maybe you can comment about this.

So I was only sick for like a half a day.

I got a fever of like 104, I just went up and then crashed.

And then I was, now, maybe I'm just seeing the silver lining of everything, but afterwards,

I have like a greater clarity about the world.

You just think it's greater clarity.

Maybe I just, it was so, maybe so intensely, the mind fog kind of thing for such a short

amount of time, but the people were involved were also reporting this.

It's kind of interesting because like, because I do know like the immune system is involved

with the brain in very interesting ways.

So like the human mind also incorporates all these other, it's not just the, it's not just

the nervous system.

And I just wanted, because everyone always says, not, not like, everyone always says

like COVID does all these bad things or whatever the disease is or whatever the virus.

But I wonder like, hate to be a Steven Pink around this, but like, I wonder what the

benefits of certain disease are, if you're like, what is there's some like, again, don't

want to romanticize it, but if your system goes to some kind of hardship and you come

out on the other end, I wonder sometimes if there's a greater, maybe killed off a bunch

of neurons that I didn't need anyway, and they were actually getting in the way.

There were the hater neurons.

Well, I don't know.

You're inner critic that I was talking about.

Exactly.

You killed off your critic.

Well, you know, there are mechanisms for what, the potential mechanisms for what you're

talking about.

There are, there's actually been a fair bit of research on post COVID neurological function.

And actually, my wife, Michelle Manje, who's at Stanford, she's done a lot of this work.

Hiko Iwasaki, Yale has done a lot of this.

But what they found is that there's a loss of myelin.

This is the coding of those long range projections that go from one part of the brain to another.

Myelin is this sort of insulator that coats these long range projections and makes the

impulses go faster and more reliably.

And there's altered function of the myelin producing cells and altered myelin in the

case of COVID.

They've looked in both mouse and human brains.

And but of course, it could be very idiosyncratic.

Many people have cognitive problems post COVID.

You're definitely aware of that.

So many people report this persistent brain fog and the ability to function.

But it depends on where the inflammation was.

Maybe the people who have dysfunction post COVID, they had a global effect.

Maybe you lost some of these projections that were restraining you in some way and these

plausibly exist and it's known that there are cell populations in the prefrontal cortex

that actively restrain deeper structures from expressing what they do.

And it's theoretically possible that you had a lucky so many has to get lucky, right?

Somebody has to get lucky.

Why not?

All right.

If we can actually go back to this idea of trying through optogenetics to find origins

of when the way first starts, origins of a decision, origin of idea, origin of maybe

consciousness or the subjective experience or origin of things in the mind.

So one thing is Carl Jung, is there a God neuron?

Is there a belief neuron?

Is there so through this methodology of optogenetics, can you start getting to like where a belief

begins or an idea begins and especially looking at the strongest of our beliefs, maybe beliefs

of love and hate, but religious belief into something like really grand on the grandest

of scale?

Neuroscience and neurology point us a little bit.

We don't have an answer to that.

But a lot of these questions I'm going to ask you, there's no good answer, but you're

providing the tools that give us hope to find the answer one day.

Yeah.

And we have early clues.

So for example, when patients with epilepsy have experiences of religiosity as part of

their seizure or the aura before their seizure, very often those are in the temporal lobe

in these parts of the brain that are at the side.

And so that's initial clue.

There are also parts of the brain that are involved in the definition of the self and

defining the borders or boundaries of the self.

And we know this, this is some experiments that we did in my lab.

There's a part of the brain where if there's a rhythm of a particular type, you can cause

a separation of the sense of self from the sense of the body.

What's normally bound up and unitary, we normally think of ourself and our body is pretty tightly

bound up together.

Those can be separated, it turns out.

We can't take that for granted and there are certain conditions, certain patterns of

activity in one part of the brain called the retrosplenial cortex where you can actually

separate those two out.

And so if you think about these very big questions, where are the origins of religiosity?

How do we define the boundaries of who we are relative to others and to the world?

How do we link ourself to our body and how can that become separated?

These are actually, believe it or not, now accessible and rigorously and quantitatively.

So we did an experiment with optogenetics where we provided this abnormal rhythm to

this particular part of the mouse brain and we saw this separation of detection of a stimulus

and caring about it.

So that's like stimulating something about the mouse brain that affects these neurons

that give the conception of self.

Also you're able to dissociate the experience from the impact of the experience onto you.

That's right.

Exactly right.

So these are the goals of meditation, these are the goals whenever I get drunk, pretty

much effective.

I mean, that's not a scientific statement, just an experiential anecdotal one.

Also psychedelics seek to attain this kind of state.

That's so interesting.

Well, you mentioned psychedelics, DMT and 5MEO, DMT, these create this religious experience,

this connection, people describe them as a strong connection to God.

In theory, these are accessible with modern methods.

Now that we have these rich recording methods, we can explore what are the precise millisecond

resolution, cellular resolution, brainwide manifestations of these altered states.

So like you could look at an altered state like on DMT recorded across many people and

then from there see where do these experiences originate in the brain in terms of single

neurons and then how do they propagate and interact with everything else and if there's

some kind of common signal, like how do you narrow down the set of neurons that are responsible

for particular experience or for particular behavioral effect?

Here's where optogenetics is so useful because anytime you give an agent like an agent like

ketamine or PCP, which we used for our dissociation experiments that I was mentioning, or you

have a psychedelic LSD or DMT for this altered perceptual state, if you give either of those,

these change everything across the brain.

That's the fact that you maybe give them to a mouse, let's say, or eventually to a human.

You won't know yet which cells to home in on as the causal players in all this just by

recording the activity.

But then what we found is that optogenetics providing a causal pattern of activity guided

by what you see can let you test hypotheses and we saw this rhythm with ketamine and PCP

for dissociation and then we said, okay, let's test what's causal.

We came in and provided that rhythm.

We tried a few different things, but only one of the causal tests we tried actually

caused the behavioral dissociation.

And so that's how we home in on what actually matters.

And is it repeatable once you see the, so like that's one definition of causality is

like you try and it repeats across different mice and all that kind of stuff.

Exactly.

And so you could do that for DMT, you could do that for the, like the really fascinating

mind expanding.

Thank you.

Thank you.

So the meme for people just listening.

This is again another disagreement between Freud and Carl Jung, religion and spirituality.

This is the, I guess the ring scene from Lord of the Rings, religion and spirituality.

Freud says cast it into the fire, destroy it.

Carl Jung says no.

So for people who don't know, Sergei is the Slavic Lord of the meme.

Thank you.

I appreciate that.

So what we're talking about, so there is, I mean, I think a connection between DMT and

religious experiences or some of these psychedelics, do you think it's possible to sort of stimulate

religious experiences?

So religious experiences are one of the most deep kind of experiences.

And so here you could first understand where they originate, how they propagate to the

brain and then to stimulate them.

And so this is, and these that can happen in people who had no predisposition, you know,

people who are, you know, as agnostic or atheistic as you'd like, they can have these, they can

feel connected to God in these, in these states.

Now, to be clear, I'm not advocating these.

We don't know what's safe in human beings, but we definitely have not yet, but we definitely

can do these experiments in mice and that was already very productive in understanding

dissociation.

So we can already imagine making headway on these methods.

And then, you know, I had a, and this does map onto the non psychedelic human experience.

I had a patient who's actually described in the book, Projections.

This was the patient that's in the mania chapter, the bipolar chapter.

Here was a guy who had never had a psychiatric illness or symptom in his life.

He was a retirement age gentleman and nobody in his family either.

So no family history, no personal history of any psychiatric illness, and he had never

been religious particularly before either, certainly no, no passionate, you know, type

of religion.

And he, not through any psychedelic or drug, he had a stressful experience, actually a

post 9.11 change in how he was thinking, and he was pushed into a mania, a manic state

revealing that he had bipolar, never before known in this case, in this person.

And his mania, his elevated state in bipolar included this profound religiosity he had,

which he'd never had before, and he was preaching in an elevated, vigorous way to his family.

And so this state can be created in people even late in life who had no predisposition

for it and no, even without a neurochemical.

So there's the causality of that is very interesting to explore.

How did the manic state unleash this religiosity?

But you see that in other realms of psychiatry too, OCD can manifest as religiosity also.

You can take people who never really had a, religion never played a powerful role in their

life, but then when their obsessive compulsive symptoms become severe, they can manifest

in this.

I think I'm in that group.

So I'm a bit OCD.

We have, there's, I think these subreddits, when it's oddly satisfying things.

So there's certain things that are really satisfying to my OCD, in my mild OCD, I think

it's pretty much a religious experience.

So I understand that there's, if it's not directed, it's at least rhymes.

So maybe can you speak to the, as Sergei is probably desperately scrambling to pull up

oddly satisfying.

Thank you.

People can check it out themselves.

It is, as the subreddit promises, oddly satisfying.

Can we talk about bipolar?

They may be depression.

Well, let's talk about, I mean, I don't know if there's a nice way to discuss the differences

in the full landscape of suffering that's here, but maybe what is depression and what

are the types of depression?

What kind of depression have you seen and experienced and researched and how can people

overcome it?

How can humans overcome it and deal with it, live with it and overcome it?

So this is my clinical specialty.

I see patients in my outpatient clinical work with treatment resistant depression.

So very hard to treat severe illness where medications haven't been working.

I also see patients with autism spectrum disorders.

These are my two clinical focal areas, but then I do emergency room work as well.

But the depression, why do I focus on that?

It's so, one feels tantalizingly close to helping these people who are suffering so

deeply.

One of the things that I've focused on it is these are people who, there may not even

be anything situational that's difficult or challenging in their life.

You can have people who seem to have everything that you would want.

Every objective measure of the life is fine, and yet they can be just hit with this unstoppable

hopelessness and inability to see into the future, a discounting of the value of their

own action.

Anything they can imagine themselves doing seems worthless or they are unable to enjoy

things.

We call this anhedonia.

There's no reward, no pleasure, not in food, social interaction, movies, books, anything

that they would enjoy, positivity gone.

They can have a profound negative internal state, psychic pain, and these things can

seem and in the severe cases are inescapable.

So what is going on?

Why is this state part of the human existence?

It's got a strong biological genetic link.

We know that.

It's been linked to certain genes, certain regions of the chromosomes, and twin studies.

There's a clear genetic link.

It doesn't explain everything, but it's a big part of it.

Sex are a strong contributor, and although you can have depression without anything terrible

going on in your life, the symptoms can be made worse by stressors, by trauma.

But at a very deep level, there's nothing we can measure in a person objectively, so

we don't have, there's not a known chemical, not a known structure that's different, not

a known brain activity pattern that we can pick up with EEG.

A lot of people are exploring this, but right now we have no objective measures.

All we do is talk to people and we elicit these symptoms.

We explore them, distinguish them from other possible causes, and then what do we do?

Well we have a range of treatments.

We have medications that can help people, do help people, but not everybody.

And if they don't work, then we can go to brain stimulation methods, we can do things

even like electroconvulsive therapy, which is very effective, but it's sort of the final

thing we go to in the end.

And so we have treatments, they work for some people, they don't do everything we'd like,

but here's the problem is at a very deep level, we don't understand really what's going on

in the brain.

We don't have a physical interpretation of the problem.

We have all these symptoms, but we can't yet point to a set of cells or a set of circuits

or an activity pattern that is causing major depression, this disease state per se in human

beings.

Why do you think you can't yet, from an optogenetics perspective, is it because there's so many

possible causes, is it so much, so many things involved?

So I think the answer is there are many things involved and all these different symptoms that

I've mentioned, those we can study and those we can fix, the individual symptoms.

And we can do this in animals to be clear.

So in a mouse, for example, we can instantaneously and precisely turn up or down the motivation

of an animal to overcome a challenge, we can turn up or down its ability to be motivated

by or we think experience reward from situations or actions, we can increase its apparent energy

level, its drive to meet challenges, we can turn up or down social interaction, all these

individual features of depression, individual symptoms, we now can point to exact projections

and cells that are causal in mediating these.

What we don't know is why all these different symptoms show up together in major depression

in the human disease syndrome and that's the mystery.

It's sort of in other fields of medicine, someone with congestive heart failure who

comes into the clinic, they have very different symptoms.

They have shortness of breath and they have swollen feet, couldn't be two more different

across the body sets of symptoms, neither one obviously related to the heart, but they're

both happening because the heart is not working as a pump.

And now, thankfully in cardiology, we understand these disparate symptoms that seem totally

unrelated can be completely understood because there's an altered pump action of the heart.

That's what we are hoping for in psychiatry and in the study of depression or any disease.

These different symptoms, the inability to enjoy things, the hopelessness, what's the

unifying principle?

Yeah, unifying.

I mean, is there some truth to that, the Tolstoy quote, that all happy families are alike and

each unhappy family is unhappy in its own way?

So basically, I mean, this is the human condition and basically the physicists long to find the

theory of everything.

Isn't understanding depression essentially require you to really have the big theory

of everything for the human mind?

I think we, it would certainly be nice to have that theory though, don't get me wrong.

I don't think we need it.

The understanding of the surgery, it would be nice.

It's also a good question if it's possible.

Yeah.

So that I have some thoughts on too.

But to this specific question, I don't think we need a theory of everything.

I think there will be unifying principles we can get to.

But even shy of that, if we can treat symptoms and that's a big step and as you say, different

unhappy families are different, different unhappy people are different.

If we have somebody who comes to the clinic and I see someone with a profound anhedonia

as one of their main symptoms, inability to enjoy things, and if I know based on optogenetics

work and animal work that a particular medication can treat anhedonia, even if it doesn't fix

major depression in everybody, if I treat that one symptom in that one person, that's

a good thing.

And so we don't need the theory of everything and we don't even need the unifying principle

to help people with insights that come from optogenetics.

How much does talking help for diagnosis and for treatment, would you say, for depression?

It's a big part of what we do.

Every good psychiatrist should be a pretty adept in these verbal communications and

talk therapy as part of what they do.

I give medications, I deliver brain stimulation treatments, but a big, big part of everything

I do with every patient is talk therapy because it works so well together with these other

modalities.

Even alone, it can help people with moderate or mild depression by itself.

People with severe depression, people with other psychiatric illnesses that are severe,

you don't want to do talk therapy alone.

It's not going to do it, but it still is crucial to do together with the others.

And it's critical because it's part of how you reshape cognitions, complex activity patterns,

and you won't get to that with a medication or brain stimulation treatment.

Do you have advice for people who suffer from mild forms of depression or feel as they might,

both for those people and do you have advice for people who love the people who suffer

from depression and want to help?

One of the incredibly frustrating things about depression is the very nature of it makes

it hard for the people who suffer to get treatment because they're hopeless, so they

don't think treatment will help.

They have low energy, so they're not motivated to participate in treatment in many cases.

Sometimes they're actively suicidal, that certainly doesn't help.

They have all these things that seem to prevent treatment from being effective.

So the loved ones, that's where the loved ones are so important is helping them overcome

these barriers to treatment, the motivation, the safety, and the insight.

That's critical, and particularly for the severe cases.

For the mild cases where people still have some insight and motivation and energy to

get something done.

There are many things you can do.

Exercise is extremely important in mood maintenance.

Regulation of sleep and getting sufficient and regular enough sleep is very important.

And talk therapy can be helpful in those mild or moderate cases.

Just looking at cognitions, looking at patterns of thought that people may have fallen into,

where they catastrophize, where they spiral from small things into big things.

A little bit of talk therapy, 10, 12 sessions, can help people identify those patterns they

may have in themselves that are taking occasional negative thoughts, which everybody has, and

magnifying those into more persistent negative states.

If you work at this, and it's kind of like homework, this is what we call cognitive behavioral

therapy, it's very structured, very organized, you work hard, it requires insight and motivation

and you have to be motivated.

But if you are, then you can identify these triggers that send you down particular pathways

and work to intercept them.

And that is amazingly very effective in mild to moderate cases.

So you basically have to train yourself to see the world as a collection of triggers.

And you have to first understand, like collect the data, like basically see every experience

as a thing that creates a follow on emotion of feeling.

And I've learned this on social media, where early on, like all of us, I'll say something,

I'll kind of respond to negativity with negativity, and then you observe the results of that.

Over time, you think, wait a minute.

This thing that I've been doing where when somebody says, you suck and you say, no, you

suck, that never produces the results you thought it might.

And so I might not want to just don't say you suck back.

And I do this through a lot of things in life.

I'm very fortunate to not suffer from depression, but I, first of all, I have had and have people

in my life who do.

And also, all of us have depression, who don't suffer from depression, have depression out.

Like it's always knocking on the door, and so you have mild, I mean, if you're very careless

with the triggers all around you, then you're just, I think all of us have the capacity

to really suffer from that kind of chemical or psychological or philosophical existential

crisis.

But then it raises a question, why are we built this way?

It seems like it doesn't make sense, right?

And here's where some of us thinking about where we came from as the human family is

kind of interesting.

It doesn't make sense that somewhere on that spectrum that it's good to detect that there's

an array of adverse forces out there in the world right now at this moment.

And to withdraw, to hunker down, to not fight, not strive, not try to meet the challenge,

and outweigh these negative forces that are present out there.

And that makes a lot of sense.

And all animals that have been studied in one form or another show this.

Even the worm that I mentioned earlier, C. elegans with 302 neurons, it can effectively

give up in challenging situations.

We've done this with zebrafish, tiny little transparent fish.

You can give them a challenging situation and they will give up.

But then if you stimulate a couple very specific brain regions in particular ways, you can

motivate them to overcome the challenge.

And if you inhibit those regions, they give up much more easily than they would otherwise.

You can do this in mice, you can do this in rats.

So this is an ancestral conserved pattern to detect that things are pretty bad out there.

And to conserve energy, to hunker down, to wait out the storm.

So as use, unfortunately, many of our maladies have useful roots in our, that contribute to

our survival, so both depression and motivation have uses.

Sometimes it's nice to just shut the hell up and huddle with the penguins versus, for

some unknown reason, venture out on your own into the mountains like a David Goggins type

character.

So what's the difference to you between, you see patients between sort of rigorous psychoanalysis.

I don't know if you consider what you do, like talk therapy and psychoanalysis.

Are they neighbors?

Are they overlapping?

They're neighbors.

Psychoanalysis is, they're relatively, it's not nearly done as much as the talk therapy,

like the cognitive behavioral therapy I mentioned.

Psychoanalysis is a little more niche now and partly because it's not, data isn't, in

terms of actual treatment of actual therapeutic effects, data not as supportive as for cognitive

behavioral therapy.

But it's still interesting as for insight, people, a lot of people still do it to gain

insight into themselves.

And in general, it's a good sort of conversation starter, those methods, you know, they're

good for getting things out.

We don't focus on dreams typically these days in psychiatry, but they're great conversation

starters.

They're great ways to get things out if people have, and so we like to use those methods

just to get the ball rolling sometimes, get people to open up a little bit.

But the actual treatment tends not to involve these psychoanalytic approaches where you are

really probing the unconscious mind and its manifestation through dreams, for example,

as the goal.

That's not the goal.

Modern talk therapy, we're really focusing on treatment, how to get people to feel better.

See, I use that as a conversation opener, the Freudian thing where I try to delve at

a bar of the deep sexual desires in a person subconscious, and I find that opens up possibilities

very quickly.

Now, what's, I mean, this is a silly sounding question, but what's the difference between

cognitive behavioral therapy and conversation?

So because I personally, as a fan of conversations, as a fan of just, I like listening to podcasts

versus like audiobook, I like both, but they're very different.

I like conversation, I like, it makes me personally very anxious, so I like to be the listener,

like a third wheel, like overhearing a conversation kind of thing.

But it's a really powerful method for humans to explore each other's mind, just raw conversation.

So do you think it can be more productive to be very systematic about it, or is conversation

itself the art form of helping each other, understanding each other and helping each

other?

There are forms of talk therapy that are essentially conversational, or they much more approach

to pure conversation.

There are, there's a befriending therapy, there's interpersonal therapy.

These are approaches that are purely talk therapy, but they're not as structured as

cognitive behavioral therapy.

Cognitive behavioral therapy is, there are manuals, there are guidelines, you can almost

go through it in a very cookbooky way, there's homework that you get done.

So it's, in its fullest form, it's very different from these more conversational strategies.

But what's interesting is, sometimes people compare them, and so you'll see almost like

randomized controlled studies comparing cognitive behavioral therapy with interpersonal therapy,

for example.

And they both can work, and actually in some studies they look comparable.

So there's, to your point, conversation and insights that come from conversation, if

done well, if done artfully, can be as powerful.

This reminds me of Robin Williams, so I have to ask you several questions here on that.

But one, one of my favorite movies is Goodwill Hunting, I don't know if you've seen it with

Robin Williams.

So as a psychiatrist yourself, can you do a deep analysis of this other famous psychiatrist,

which is the movie character played by Robin Williams at Goodwill Hunting?

Is it just a caricature between a psychiatrist and patient relationship, or is there some,

something to you that was moving about his ability to connect to this obviously struggling

young kid?

I think you've hit on the key thing there, which is the depth of the connection.

If there's too powerful a connection, that can impair therapy because it could impair

open communication.

If someone, if a patient has a, sees the role, sees the relationship in a particular way,

like in a friendly way, maybe, or like a parental child type way, that can cause problems because

then what they choose to share, what they choose to bring up is selected to be appropriate

for that view of the relationship.

And so I and many other talk therapists actually prefer not to let things get, not let the

connection get that deep.

You want to have trust, you want to have a therapeutic alliance, we sometimes call it,

but it's got to be enough of a blank slate that the patient is not consciously or unconsciously

constrained in what they choose to share.

And so great movie, great actors, all good, no complaints except realistically the relationship

should be a little more arm's length than that.

Let's pretend this is real life.

Sometimes can't you leave a little bit of yourself in the interaction with the patient?

I mean, it's another human being.

Yes.

So it's a balance.

Actually, you do need some of it because let's say this person is having challenges, interpersonal

challenges in their life.

The best way to notice what those are and to identify them and to work with them is if

you can elicit some of those problems in the office, in the therapeutic interaction.

And this is really powerful as long as you're alert to it, aware of it, and you don't let

it get out of hand.

This transference, we call it, is when you transfer in between the current therapeutic

relationship and external relationships that the patient may have had with others.

And so if the therapist starts to feel an inner feeling like anger, let's say, so let's

say you have a patient who is stirring frustration in you or even in extreme cases, anger, the

best thing for the therapist to do in that case is to recognize it and to realize that's

probably being stirred by other people in the patient's life.

And that could be the source of a lot of problems.

And so instead of trying to wall it off and say, oh, I shouldn't be feeling that, I better

be a better therapist instead and recognize it and use it and help the patient that way.

And so you've got to be a human being, you've got to be a person who feels, you've got to

be open.

But being controlled and be aware of it.

If I may, I just want to read the, because this is my favorite scenes, probably one of

the greatest scenes, one of the greatest scenes in movie history because Robin Williams does

a single take.

So this is a very interesting interaction between them.

So Will, and I'm sure this is a common interaction, maybe with a therapist and a patient, maybe

with a father and son, where Will, the young character, they're a young brilliant mathematician

and Sean is the therapist, the older therapist where Will looks at a painting that Sean painted

and then does a, like a deep critical analysis of the painting that basically, you know,

describes, pretending as if he can understand another human being completely by just looking

at their painting.

And then Sean gives this whole speech that contrasts sort of raw intelligence and the

wisdom of experience.

And Sean says, single take.

He says, you've never been out of Boston, right?

And Will says, nope.

All this in a sexy Boston accent, by the way.

And then Sean gives the speech.

If I asked you about art, you'd probably give me this skinny and about every art book

I've ever written, Michelangelo.

You know a lot about him, life's work, political aspirations, him and the Pope, sexual orientation,

the whole works, right?

But I bet you can't tell me what it smells like in the Sistine Chapel.

You never actually stood there and looked up at that beautiful ceiling, seen that.

If I asked you about women, you'll probably give me a syllabus of your personal favorites.

You may have even been laid a few times.

The language here is just beautiful.

But, but you can't tell me what it feels like to wake up next to a woman if you're truly

happy.

You're a tough kid.

If I asked you about war, you probably throw shakes bare at me, right?

Probably not.

Let's say, once more into the breach, dear friends, but you've never been near one.

You've never held your best friend's head on your lap and watched him gasp his last

breath, looking to you for help.

If I asked you about love, you'd probably quote me a sonnet, but you've never looked

at a woman and be truly vulnerable, known someone who can level you with her eyes, feeling

like God put an angel on earth just for you, who could rescue you from the depths of hell