School Shooters, Long COVID, Medical Cannabis (w/Dr. Rachel Zoffness)

– [Zubin] Rachel Zoffness, we’re back together. You and I, we’re doing a new show. This is Dr. Rachel Zoffness. She is a UCSF Assistant Clinical Professor and a Visiting Professor at Stanford in Pain and Health Psychology, which is cool. You’ve been on the show like five… This is the fifth time?

– [Rachel] I think it’s the fifth time.

– [Zubin] So I have this rule, when you’re on more than four times, we name it a show and we do it monthly. What do you think?

– [Rachel] I am so down.

– [Zubin] And I’m thinking we call it Pain Points with Z Squared or Dr. Z and Dr. Z or Z and Z?

– [Rachel] I think those all sound like great ideas, and I think we got some of those ideas from some of your fans.

– [Zubin] That’s correct, because we put out a call, right? We’re like, we’re gonna do this show, we’re gonna talk about pain, we’re gonna talk about mental health. We’re gonna talk about health and the biopsychosocial integration of the human condition, and we put it out to supporters and they gave us lots of great questions, and we’re gonna go through their questions.

– [Rachel] Totally, and I put out an SOS on Twitter also.

– [Zubin] And it worked really well. I saw your responses.

– [Rachel] People had a lot of questions for us.

– [Zubin] Dude, so many people have messaged me and they’re like, “Man, every time you get Rachel Zoffness “on the show, I learn so much. “It validates what I’m going through.” There’s a lot of suffering in the world, girl.

– [Rachel] There’s a lot of suffering, and what I like about our dynamic is A, I think we’re just aligned psychically and potentially spiritually, whatever that means. I don’t know.

– [Zubin] Whatever that means, I’m down for it.

– [Rachel] Yeah, but also having a psychologist and a physician in conversation about health, and by health, I mean the brain and the body together, is very rare. It just doesn’t happen that often, so I think it’s a unique opportunity to talk through common conditions that happen to humans and to get a physician perspective and a psychology perspective. It’s like, oh, brain and body are actually connected 100% of the time, so let’s talk about health that way.

– [Zubin] I love it, and speaking of brain and body connection, I just got my booster.

– [Rachel] Dude.

– [Zubin] From Moderna, and the reason I did it, I’ve been hesitating, because I’m like, well, I’m relatively not old and I’m not exposed a lot, but this is what pushed me to get the Moderna booster, which is a half dose booster, was, well, I’m going to be traveling with the family for Christmas, I’m going to see my elderly parents, who are vaccinated and boosted, and I also just wanted to figure out what kind of side effects I would get, because the second dose kicked my ass.

– [Rachel] Right, you said that.

– [Zubin] Right, it was horrible. I had the man flu and all that. So now, I’m about 24, almost 24 hours out from the booster, and I have a little achiness, a little headache, a little bit of brain fogginess, but it ain’t bad.

– [Rachel] Like a little lower energy.

– [Zubin] A little lower energy, that’s it. I’m like low energy Jeb, as Trump used to call Jeb Bush.

– [Rachel] Oh, wow.

– [Zubin] Yeah, right? “He’s low energy. “He’s low energy. “You want to be president. “You’ve got to be high energy, Jeb.” I’m trying to rev up my energy by channeling Trump.

– [Rachel] Great, I got the booster also. I had no effect from shot one, also Moderna, no effect from shot two, but the booster-

– [Zubin] Oh, really?

– [Rachel] Yeah.

– [Zubin] Moderna?

– [Rachel] Yeah, look, I don’t want to overdramatize, but I was very sweaty and shaky and felt very fevery. I did not take my temperature, but I’m pretty sure I had a fever and I just piled on lots of layers and lay on my couch under lots of blankets and drank lots of tea and binge watched Netflix, so it was a really fine-

– [Zubin] And people don’t want to get this vaccine, why? That sounds like an ideal night. I would pay for that.

– [Rachel] Except for the sweating, shaking part, yeah.

– [Zubin] No, but that stuff is just like… It just adds drama. Netflix and chills. You see what I did there?

– [Rachel] That was funny.

– [Zubin] This is why we’re Dr. Z and Dr. Z.

– [Rachel] That was a good pun.

– [Zubin] We’re ZZ Doc. You see what I did there?

– [Rachel] I do. It’s good. I liked it.

– [Zubin] It’s terrible. I’m sorry. Listen, let’s take these questions, ’cause they’re really good. One of them was like, what?

– [Rachel] Can we start by saying a couple of really important things? Which is like-

– [Zubin] Right, some disclaimers. So listen guys, I’m going to say this right to the cam cam. This is not medical advice. Dr. Rachel is not your doctor. She’s not your mom. She’s not your sister, okay? She’s not in your band. She is here to inform, entertain and educate, and this is not medical advice, so remember that. Talk to your own practitioner about these issues.

– [Rachel] And same for you.

– [Zubin] And same for me.

– [Rachel] The advice you’re giving.

– [Zubin] But this is all understood.

– [Rachel] Also not medical advice.

– [Zubin] because people know I’m a two-bit clown, and they’re like, “I’m not going to listen to anything he says about health. “Come on.”

– [Rachel] Why isn’t he in a Darth Vader costume? That’s why I’m here.

– [Zubin] Exactly, right?

– [Rachel] Why am I even here? We could do the next one in full costume, just to sass people.

– [Zubin] I like that, and that’s the kind of mask that we ought to be wearing if we’re trying to prevent Omicron, ’cause we all know that Omicron, right?

– [Rachel] Darth Vader mask?

– [Zubin] Darth Vader mask.

– [Rachel] Good.

– [Zubin] Full res…

– [Rachel] I have a butterfly mask. I don’t think they match but…

– [Zubin] This sounds like an anime fetish. Why do I suddenly want three of these?

– [Rachel] And in episode six, we’re going to be furries.

– [Zubin] In episode six, we’re gonna be furries.

– [Rachel] Yeah.

– [Zubin] That came out of your mouth.

– [Rachel] It totally did.

– [Zubin] You know what? This is a family show.

– [Rachel] Sorry.

– [Zubin] It’s not.

– [Rachel] I’ll behave, yeah.

– [Zubin] It says explicit on iTunes, I think. I don’t know what that means.

– [Rachel] Adult . There’s so many options for where this could go. How exciting.

– [Zubin] Well, now that we’ve done all of this, I feel like I need to reestablish our credibility on these topics. So we’ve had a few shows where you’ve really brought to the fore this idea that everything from pain, anxiety, certain physical symptoms, diseases like even hypertension, are biopsychosocial, meaning they have biological physical components, they have psychological mental components and they have social components. So when we answer these questions today, we’re going to do it through the lens of this.

– [Rachel] That’s exactly right.

– [Zubin] Yeah, and you’re the mistress of this. I almost said master, but that would have been gender normative.

– [Rachel] I’m fine with either, really.

– [Zubin] Okay, good.

– [Rachel] You can call me the master of whatever you want.

– [Zubin] Master of puppets?

– [Rachel] No.

– [Zubin] That was a Metallica thing.

– [Rachel] I’m not a puppet master.

– [Zubin] Well, you should think about it.

– [Rachel] But to your point, about the biopsychosocial thing, the thing about human beings in medicine is that, in medicine, what we often do is we distill human illnesses and ailments down to the purely biological or biomedical. So for example, with pain, which, of course, I talk about a lot, pain is treated as a purely biomedical biological problem, and because we frame pain that way, we treat it with purely biological or biomedical solutions, like pills and procedures, but A, it’s not working, chronic pain is on the rise, it is not decreasing, and B, we now have an opioid epidemic, and I think the rates of overdose during the pandemic, originally CDC estimated it was like 38% increase. Now, 54% increase in opioid overdoses and deaths. So a lot of those had nothing to do with pain by the way, so I don’t want to suggest that that’s all pain-related. However, in general, human beings, and this is something everyone knows, are never purely biomedical. There are a million things going on with human beings all the time. We are very complex. So there are cognitive things, what’s happening in your head, what your head is saying to you affects your body 100% of the time, and I hope we get to that today. Emotions affect the body 100% of the time. If you’ve ever had butterflies in your stomach or sweaty palms or a racing heart when you were anxious, you know that the brain and body are connected 100% of the time when it comes to emotions. There are social and sociological components to health all the time. There’s research that shows that when people are isolated and lonely and alone, their cortisol spikes. Cortisol is…

– [Zubin] A stress hormone.

– [Rachel] And what does it do to the immune system?

– [Zubin] It actually suppresses it.

– [Rachel] It tanks your immune system. So lonely people who are lonely and alone, by the by, oftentimes have higher morbidity and mortality rates, meaning if you’re healthy, you’re more likely to get sick, if you’re sick, you’re more likely to get sicker, and if you’re really sick, you’re more likely to die if you are lonely and isolated and alone. What does it say about human health that we’re ignoring the psychosocial components of our wellness? How is anyone supposed to get better if we’re only focusing on the bio, when we know that health is biological and psychological and social, or sociological? So that, you’re right, I agree that that’s a very important frame for every question we get asked.

– [Zubin] And I’m going to triple down on that and say, during our COVID pandemic, what we’ve done is focused on the biological and we’ve destroyed the social and the psychological. I’m going to triple down. You don’t have to agree with me on this, but I’m just going to say this right now. What we’ve done is created a pandemic of anxiety, depression, loneliness, hopelessness, fear, and we see it manifest in everything from children, to the increased suicide rate and increased overdose rate. I think it’s all a vibrating waveform of this complex holistic truth that we are, and until we can look at that holistic picture, we’re never going to actually do good with public health policies. So that being said, speaking of doing bad, one of the questions we got was, and it was after a recent school shooting, what makes a kid a killer? So how does this happen? And I know nothing about this.

– [Rachel] I know, and you and I have spent some time thinking about it, because a lot of the questions that we got… I work with a lot of suicidal teens. I have never, full transparency, worked with a kid who was homicidal. So there are a lot of things to say about that. I actually want… Can I go big picture before we go?

– [Zubin] Please.

– [Rachel] So I just want to say, in general, and I’ve said this before, it is actually normal for human beings, in the course of their lives, to have suicidal thoughts, and I’m going to say what I mean by that. I’m not saying everybody does, but it is not unusual and in the realm of normal to think things, like, “Things are really bad right now. “It would be better if I weren’t here.” Or, “Gosh, it would be such a relief to not have to deal “with all of this emotional and physical pain. “I’d rather be dead.” Or when you’re a teenager and life is going sideways, when you’re a teenager, things feel really permanent, like, “I’ll never have a boyfriend,” or, “I’ll never get boobs,” or like, “No one will ever ask me to a dance.”

– [Zubin] That’s how I felt. I’m like, “When are these going to come in? “Bobby’s got his boobs.”

– [Rachel] Totally, “Everyone else has training bras.”

– [Zubin] I was like, “Are you there, God? “It’s me, Margaret.”

– [Rachel] Exactly.

– [Zubin] Sorry, I don’t mean to make light of suicidal thoughts.

– [Rachel] You’re not making light of suicidal thoughts. You’re making light of teenage angst, which is absolutely appropriate.

– [Zubin] And man boobs, which are not. Gynecomastia is not funny.

– [Rachel] I’m not making fun of that either.

– [Zubin] All right, just want to make sure.

– [Rachel] Right, so good, thank you.

– [Zubin] So these thoughts come through, and the permanence, this permanence delusion that, “Oh, this is going to be forever. “I’m never going to have this.”

– [Rachel] Right, that’s common in teenagers, and it happens throughout our lives. When you’re in a bad situation, it often feels like this bad situation will never end, like the pandemic. We’re all like, “Oh my God, is this permanent? “When is this ending?”

– [Zubin] Of course, in this case, it never will end.

– [Rachel] Don’t say that!

– [Zubin] Because, come on, guys, let’s be serious.

– [Rachel] Please don’t say that.

– [Zubin] We’re only on Omicron. There’s still several Greek letters to go.

– [Rachel] Okay, your hopelessness is not penetrating my mind.

– [Zubin] Hey, for me, the glass is half broken, all right. I’m sorry, back to you.

– [Rachel] Okay, so I also want to say, perhaps controversially, it is also not abnormal for humans, teens, adults, to occasionally have aggressive or homicidal thoughts.

– [Zubin] Yes, please talk more about this.

– [Rachel] Sure, sometimes people wanna hurt people very violently, and you think about it in your head, like someone messes with you at work, or your boss fires you, or someone you love acts like a complete a-hole, or someone wrongs you or physically hurts you, it is normal to think violent, aggressive thoughts. There’s some quote that I’m gonna forget, but it was something like, “A violent thought a day keeps the psychiatrist away.”

– [Zubin] Oh, wow.

– [Rachel] So you and I have talked about tea-kettling before?

– [Zubin] Right, where you blow off the steam by releasing emotion.

– [Rachel] Right, negative emotions live in your body, not just in your head, and they have to come out in some way, so people punch a punching bag, or they rip a phone book, or they scream really loud in their car, or people come up with strategies that work for them. I go for long runs, or whatever, or talk to friends. There’s lots of ways of working that shit out. One way of tea-kettling is thinking the aggressive thoughts that you’re not actually going to act on. So that’s aversion. Now, when suicidal ideation and homicidal ideation, and again, ideation is just thinking about it in your head, becomes active, that’s when everyone should get worried, and I’m saying this very importantly, proceeding this conversation we’re about to have about children who go into schools with guns and kill people, their peers, who are also children, and commit violent crimes that they’re never gonna come back from. These kids are never gonna be okay. The kids who commit the crimes, they clearly weren’t okay, but now they’re really never gonna be okay, and I don’t mean to be dramatic about that, but when you’re 15, and now, you’re a murderer, I wonder how that goes for you for the rest of your life? So something that we all need to look out for, and you please interrupt me if I’m going, great, something we all need to look out for is when passive ideation becomes active ideation. So the suicide part, I’ll say first, ’cause it’s easier for me, ’cause that’s my realm of experience, and I’ve seen both happen, passive suicidal ideation, someone comes to my office and they’re like, “Things have been so badly. “I just wish I wasn’t here anymore,” or, “Man, I’d rather be dead,” or, “I’m having thoughts of hurting myself, “but I would never do it.”

– [Zubin] Mm-hmm, so passive.

– [Rachel] Passive. Active suicidal ideation I have also seen. It sucks, and it is, “When I leave here, I’m going to get a razor blade.” I don’t want to trigger everybody, so trigger warning, but, “I’m gonna get an object and I’m gonna harm myself, “because I don’t want to be here tomorrow,” or active is also, “I’m ready to die. “I’ve given away some of my belongings. “I’ve talked to a couple of friends about. “This is the end for me and I’m done, and so here’s my plan. “Over the next couple of weeks, I’m going to X, Y, and Z, “and then get this weapon, and that’s my plan.” And to be more concrete, what separates or differentiates passive from active is plan and intent, plan and intent. If someone has a plan of how they’re going to kill themselves, or someone else, plan. Intent, are you going to do it? The same is true with homicidal ideation, homicidal ideation… I’m not worried about you if you’re like, “I’m going to effing kill everybody. “I’m so pissed off.” A lot of us has said that.

– [Zubin] That’s just Tuesday for me, yeah.

– [Rachel] Exactly.

– [Zubin] It’s anytime I see Dr. Oz on TV.

– [Rachel] kill that guy. Dude, don’t.

– [Zubin] I never said the K word with Dr. Oz, all right? I’m not trying-

– [Rachel] No, no, no, no, no, right.

– [Zubin] But mentally, in my mind,

– [Rachel] With the thoughts, sure.

– [Zubin] Like, yeah, we’re on an island somewhere, there’s only a limited amount of food and I hoard it all, and he dies of starvation.

– [Rachel] Totally.

– [Zubin] It’s a passive death.

– [Rachel] Right, it’s not aggressive.

– [Zubin] No.

– [Rachel] It’s not violent even.

– [Zubin] No, no, it keeps the psychiatrist away, those thoughts.

– [Rachel] Those thoughts, apparently I’m told.

– [Zubin] Yes, my mother is a psychiatrist and it keeps her away. There are many things that keep my mother away from me. Yeah, that’s a whole nother conversation. Anyways, back to you.

– [Rachel] Which maybe we can have sometime.

– [Zubin] Yes.

– [Rachel] Right, so active homicidal ideation is you have a plan and you have intent to carry it out, so anyone who’s been following this recent Michigan shooting with a 15 year old child, he had told a couple of people on a social media site that he planned to do it. He announced he had a gun.

– [Zubin] So intent, plan.

– [Rachel] That’s what I want everyone to hear. What I want everyone to hear is there was intent. There was plan. This is a child who had active homicidal ideation, active. He drew a drawing of children who had been killed. He drew bullets. The teachers found it. They were very worried, blessings. There was blood everywhere in the drawing. There was also a smiley face emoji and it said, “Help me. “The thoughts won’t stop.”

– [Zubin] Oh my.

– [Rachel] Oh, dude, I’m telling you. My heart breaks when I read. Right, then the teachers caught him or someone, I think it was a teacher, saw him Googling where to buy ammo. Passive or active?

– [Zubin] Active.

– [Rachel] That is the right answer. Now, I do not assign blame to anyone. Teachers are among the most amazing humans on the planet, in my humble opinion, and are doing a great service and should get paid what basketball players get paid, and I think we should swap that actually.

– [Zubin] Yeah.

– [Rachel] Let’s swap those salaries, but they’re not trained to know what suicidal and homicidal ideation are, what passive versus active looks like, and when you act. So again, passive, I do not get worried. I’m concerned and I want to talk about it and you want to figure out… Something’s going on. Active, you effing call 911, period. You don’t call the parents. You don’t have a school meeting. When a child is drawing pictures of dead children and Googling where to get ammo, that is active homicidal ideation. You call 911. I’m saying this because part of me wants to prevent this whenever… Can I? No, but the more of us know the difference, the more we know what to look for, I think the more will change. I think if those teachers had known that, they would have all jumped to action. By the way, mom, the kid’s mom, also knew. She texted him, “Don’t do it.”

– [Zubin] Oh my.

– [Rachel] Don’t do it. Instead of don’t do it, you pick up the phone and you call 911. I know that’s not casual for a parent to call 911, but do you know what would have happened, Zubin? If she had called 911, instead of texting, “Don’t do it?” She would have saved her child’s life.

– [Zubin] Life, and the lives of the other children.

– [Rachel] But to be clear, she clearly wasn’t worried about those other kids in that moment. She was only worried about her own. If she had called 911, she would have saved his life. Why? He wouldn’t have become a murderer.

– [Zubin] So would they have involuntarily held him in a psychiatric-

– [Rachel] Correct.

– [Zubin] Yeah, homicidal ideation.

– [Rachel] Yeah, he would have had full safety assessment. They would have been like, “Oh.”

– [Zubin] Homicidal intent, sorry, plan, yeah.

– [Rachel] Yeah, they would have realized he’s actively homicidal, he’s unsafe to self and others, he would have been involuntarily hospitalized, they would have found the gun, they would have done a full assessment and discovered that this child wasn’t okay.

– [Zubin] Do you think law enforcement is overwhelmed with these kind of calls already or do you think they’re not getting enough of these calls when it’s appropriate? What do you think’s going on?

– [Rachel] I think they’re not even remotely getting enough of these calls when appropriate, and I don’t actually know if… My understanding is when a 911 call like that goes in, I think there is a mental health crisis team that comes in and performs an assessment, a safety assessment is what we call it, and I’ve seen that for active suicidality, but because I’ve never reported active homicidality, I think, my understanding is that it’s pretty similar. It’s not like the kid gets shot, and he wouldn’t have even been imprisoned. He didn’t commit a crime yet. He had a gun and he was 15, but it was a gift from his parents, amazingly enough, and that’s a whole other fish to fry.

– [Zubin] That’s another discussion. So what is it, do you think, that made this kid…? That’s a bigger, difficult question. What generates the homicidality? Is there a particular pattern? What have you learned on this? ‘Cause it’s not common knowledge.

– [Rachel] No, it’s not, and again, I am not an expert on this. I just have gone down this rabbit hole, because what happened to that 15 year old child? What broke him? Something happened. Do you have thoughts on this? About what happens to a child that they get to this place where they’re-?

– [Zubin] Well, I think it’s interesting because it’s predominantly a masculine issue, it’s predominantly boys that this happens too, and that makes it interesting in that you have a mass shooter male phenotype there, so there’s something going on with that interaction between maleness, whether it’s testosterone or other things, and some psychological, biopsychosocial disturbance, right? And again, the most I know about school shooters is from listening to “Jeremy” by Pearl Jam, and I don’t know that that’s psychologically or medically accurate. Are there particular characteristics? What is it? Because it would help, I think, teachers and others and parents screen for these situations, if it’s like, well, it’s usually an introvert, it’s an extrovert, it’s somebody who’s had trouble in school, somebody who hasn’t had trouble in school. Is there a pattern that you think is there?

– So because we’ve got a bunch of these questions and because I wasn’t confident I understood myself why this happens, I just started reading a bunch of stuff, ’cause I’m a nerd, which is why we get along, yes.

– [Zubin] Okay, that’s right.

– [Rachel] And then I started asking some of my teenage patients. Oh, it’s been wild.

– [Zubin] Oh, tell me, tell me.

– [Rachel] Yeah, they came up with a lot of really interesting things that confirmed what I had already been reading, so often-

– [Zubin] How dare you ask the subjects of your research what’s going on, and children are to be seen, not heard.

– [Rachel] Yeah, right, kids are so wise. Kids know all the things. They know what’s going on at home, like any parent who thinks that the kids don’t know what’s going on between you and your partner, they know all the things, and I say this as a psychologist. Kids come in and they tell me, “My parents are about to break up,” or, “My dad is just staying with my mom until I get out of here and then…” They know everything. It’s pretty wild, so kids are very wise. So one of my kids said, “I have noticed,” and he’s right, “that the majority, if not all the kid shooters have been white suburban male.” White suburban male. He said, “I noticed that a lot of them seem suicidal.”

– [Zubin] Ah, interesting.

– [Rachel] Which is so fascinating to me, because that’s a different thing. “I want to die,” in my mind is a different category than…

– [Zubin] I want to kill someone else, but can they be conflated or can they be merged and both be true? Yes.

– [Rachel] And they can both be true, and it turns out that, in my mind, when you’re suicidal, you have nothing to lose.

– [Zubin] Right.

– [Rachel] So all the rage, all the anger, all the unhappiness, all the unfairness, and to top it off, you have nothing to lose, and it might be that nothing to lose that pushes you to do the thing that’s essentially going to end your life anyway.

– [Zubin] Right, exactly.

– [Rachel] So that seems non-trivial that a lot of these kids are suicidal, and what that means is they’re hopeless, they have no positive sense of the future or their place in it, and again, they have nothing to lose by doing this terrible thing and taking all of these lives.

– [Zubin] So it’s really part of a spectrum with adolescent suicidality, that perhaps there is a variant of this that actually also bleeds into the homicidality, and maybe there’s a component of some conditioning, some genetic predisposition, some social stuff that’s happening, some parental stuff that’s happening, that conflates it all into this thing that is basically a powder keg and it doesn’t get the help for the suicidal ideation or the alienation and the white suburban kid is interesting, and then it explodes. On a different end of that spectrum is death by… Or suicide by cop, right?

– [Rachel] I think that’s part of this for a lot of them.

– [Zubin] Yeah, where it’s like, “I know I’m gonna die when I do this. “I want to die with a sense of whatever. “I’m gonna take people out with me. “I have nothing to lose.”

– [Rachel] Right, so there is like a grandiosity, attention seeking, infamy component for a lot of these kids.

– [Zubin] Right, Dylan what’s his name in Colorado had that.

– [Rachel] Yeah, right, so that’s exactly right. So you get named on famous podcasts if you shoot up a school. So now, what I’m going to do forever more is never name names.

– [Zubin] Never name ’em.

– [Rachel] I’m never naming any of the kids.

– [Zubin] That’s why I said what’s his name.

– [Rachel] Yeah, what’s his name? That’s right. No, but everyone, at this point, everyone knows the name, like the Columbine, it’s famous, and I think, for a lot of these… One of the people asked about copycats. What’s very compelling for a lot of the copycats is the fame and notoriety. What teen doesn’t want to be notorious? And so when there’s this combination, this biopsychosocial recipe of horrible things that happens, that turns a 15 year old into a murderer, one of those things is this notoriety and attention seeking, and as you’ve said in the past, kids are always seeking attention, and sometimes they don’t know the best ways to do it, so negative attention seeking, hey, yo, that’s still attention.

– [Zubin] It’s attention, yeah, better than being ignored. So what do you think parents…? Parents should just be vigilant for these signs? ‘Cause I know there’s probably a lot of parents right now who have kids that have maybe behavioral disturbances or male… They’re into violent video games or whatever the usual stereotypes are of this stuff, and they don’t know when does it get to a point.

– [Rachel] Right, so I remember the first thought I had when we were looking this up, like what makes a 15 year old into a killer? Killers are made, not born. Killers are made, not born.

– [Zubin] So even a born psychopath, it’s not enough to make them a killer?

– [Rachel] So that term, psychopath, is a DSM diagnosis, antisocial personality disorder.

– [Zubin] Correct.

– [Rachel] Right, every single thing in the DSM is a biopsychosocial recipe.

– [Zubin] Uh huh.

– [Rachel] There’s not a single thing in the DSM that isn’t biopsychosocial. What has happened to this child in his home life? What kind of abuse? So to answer your question, part of the biopsychosocial recipe is physical or emotional or sexual abuse, often, this is often, not always, witnessing domestic violence at home, witnessing adults and parents modeling aggression and violence as a way to solve a problem, parental mental health problems, parental substance abuse, being the outcast at school and being rejected and being bullied and being the kid that isn’t liked, and what I want to say about that, and I want to say this carefully is, if you ask me, I knew who those kids were in my school and I was worried about them.

– [Zubin] Yeah.

– [Rachel] You too?

– [Zubin] Yeah, I did, yeah.

– [Rachel] You can think about it. So back to that thing, kids are wise. Kids know the other kids who might not be okay, and I want to be clear. I am not saying that children can point out the next school shooter, totally not, but kids know who the kid among them is who is rejected and isolated and dark and maybe just not okay, because there’s some real bad shit going on at home, and they’re getting the crap kicked out of them or whatever’s happening between-

– [Zubin] Worse, yeah.

– [Rachel] There’s just things that are not okay, and again, it’s not just what’s going on at home. There’s a biopsychosocial recipe happening here. The kid’s also being bullied at school. They’re not succeeding oftentimes academically. Biologically, they may be prone to depression, or grandiosity, I read, or again, a tendency towards violence. They may be really fascinated or obsessed with past shootings and they talk about it a lot and they draw a lot of pictures of… And I’m always trying to be careful, ’cause so many boys in our culture draw guns constantly and want guns. My brother wanted guns, like cap guns and all the guns.

– [Zubin] You’ll shoot your eye out. ♪ You’ll shoot your eye out ♪ ♪ You’ll shoot your eye out ♪

– [Rachel] What is that from? “A Christmas Story?”

– [Zubin] “A Christmas Story,” mm-hmm.

– [Rachel] Yeah, right, it’s part of American culture.

– [Zubin] Right, and that kid was bullied and that kid was an outcast and that kid had parents that were having some difficulty with the lamp that looked like a leg.

– [Rachel] Totally.

– [Zubin] Of course, it’s the most mild form

– [Rachel] So mild.

– [Zubin] of adverse childhood experience that that child could have. Anyways, back to you.

– [Rachel] That’s right, no, no, but you just… That’s right. So one can easily see that it’s a recipe of all of these things together. It’s not just one thing. It’s not like a kid has depression and has been drawing guns. He’s probably gonna be a shooter. It’s not that at all. It’s this total recipe of toxicity, and also, part of the recipe is nobody’s stepping in.

– [Zubin] Right, no help.

– [Rachel] No, I remember, when I think back to the kids in my school who I was like, “That kid’s not okay,” can I tell you a story?

– [Zubin] Yeah.

– [Rachel] It’s a little bit embarrassing. I’m not sure I should, but I’m going to. I was in sixth grade in Mrs. Feltonstein’s class, and she had pushed four of us together, she had grouped us in groups of four, and there was a girl in my group, let’s call her Penny, that was not her name, and Penny was not okay. I don’t exactly know what I mean by that. It’s hard for me to find the language, but behaviorally, she was just off. Socially, she was off. She couldn’t find the right things to say. She said things that were a little off the wall. Behaviorally, she was leaping from here to there. It was hard for her to sit still. When she tried to play with you, was overly aggressive, so people just didn’t want to play with her. Everyone stayed away from her. She was-

– [Zubin] The self-fulfilling prophecy of isolation.

– [Rachel] And people were mean to her, never me, but people were mean to her. She was bullied and she was different. She was very different. She dressed differently, her hair was always messed up, and one day, in our little pod of four, she very casually started telling this story about how she was being physically abused at home, and she showed us these marks all over her arms.

– [Zubin] Oh my God.

– [Rachel] And I was a hyper, still am, hypersensitive little kid and I did not know what to do. I knew that I needed to help Penny. Penny needed help. She was telling us that she was being hurt at home. We saw these horrible bruises all over her and nobody was helping her, and I went to Mrs. Feltonstein, and I said, “I don’t want to get in trouble, “but someone needs to help Penny. “Penny is not okay.” So the teachers got involved, I never knew what happened, no one ever told me, but I think what I’m humbly submitting here today is all the kids at all the schools know the kids who are not okay. What would happen if we mobilized our wise, wise children as the first red flag screen for the kids who need a little extra support and need some eyes on them and maybe would benefit from a school counselor and maybe a peer support group? What about that?

– [Zubin] Oh, wow, that story. So these are my thoughts, and for what they’re worth. Yes, and also, oh boy, and the oh boy comes from this. Children also are very good manipulators of other children, and bullies, so imagine they now have the power to point out someone who’s different to the teachers and have an intervention, which is humiliating if you’re not requiring it, and is also a power differential with the kids in the masses, so that’s the only caveat that I think of, but imagine if the kids were actually taught early on some degree of emotional intelligence, that they could then say, “But this is the thing,” and it’s not just about them, it’s about you, because that person could become the next school shooter, but also, don’t you feel for this person? Because you know this idea that when we bully kids, when we’re in school, and I’ll tell you this with full transparency, I was bullied, I was also a bully, both, in a spectrum. There were at least a couple kids that I used to pick on, and there were at least 20 kids that used to pick on me, and it was my way of feeling like, okay, I’m somewhere in the hierarchy that isn’t the bottom, right? And this is, I don’t know, third grade, fourth grade, whatever it is, and to this day, I feel guilty about the little boy or girl that I picked on, and what’s crazy is they came up on an Instagram feed and had somehow, years later, showed up in and saw me as, whatever, pseudo celebrity.

– [Rachel] Your bully or the person you bullied?

– [Zubin] No, no, the person I bullied.

– [Rachel] Wow.

– [Zubin] And they emailed me and said, “Oh, do you remember me? “I still live in this town and I do that.” And I was like, do I remember you? I still have so much guilt over how I behaved as a child, ’cause now I have the abstract reasoning to be able to go, oh my God, what was I doing? And I actually apologized to this person.

– [Rachel] That was going to be my next question.

– [Zubin] Do you remember when I used to do this or that or pick on you and this and that, and they were just like, “Oh, no, I just figured that’s just how kids are.” And I’m like, “It’s not how kids are and I don’t think “that’s what you really think. “You’re being nice.” But this idea that children could be educated, if they could put themselves in another person’s shoes, like what you just described, like she’s off, she’s off, and the initial judgment response is, yeah, there’s weirdos everywhere, and then you talk about what’s actually happening at home and what they’re going through, and suddenly your heart opens and you go, oh my God, that could easily be me.

– [Rachel] Yeah, so this scenario that I imagined would have much more thought about behind it than just my little ruminating, and I don’t mean flagging out the loners. I was the loner library mouse. I sat alone every day in the library, reading books.

– [Zubin] I would have totally turned you into the principal, like, “I think she’s the next school shooter.”

– [Rachel] So I don’t mean that, and I don’t mean it in a tattletale way either. This is not a thing where we’re getting revenge on the loners.

– [Zubin] No, of course, yeah.

– [Rachel] This is a thing where we’re just saying compassionately to teachers, “Hey, I’m wondering if this person is okay “and can we invite them to the next peer group or whatever.” It’s not a tattletale situation. It’s not a leveraging thing, but I see where it would go sideways. So we would just have to be very careful with this plan.

– [Zubin] We’d have to teach, yeah.

– [Rachel] But can I ask a question?

– [Zubin] Yeah.

– [Rachel] Why, if you’re comfortable answering, why were you bullied and what were you bullying the other kid about? And I’ll tell you why I’m asking after you answer.

– [Zubin] So I was bullied because I was chubby and not very good at sports at all, ’cause my parents didn’t value that at all, and kind of had a funny name, in a pretty white bread farming conservative town. and I was weird. I’m a weird kid. So meaning I’m probably… You called yourself a bookworm library mouse. I was the guy who had a telescope and wanted to be an astrophysicist and would grow plants in my room because I was fascinated by how chloroplasts worked and stuff like that.

– [Rachel] I wish we had been friends.

– [Zubin] Oh, we would have been totally. God, it would have been the story for the ages, and so who I bullied was actually me, just a little bit more on a different spectrum of that, so a little overweight, a little weird, foreign, right? Not bullied for those reasons, but it was non-specific bullying, but I know why I targeted them now, in retrospect, and they were clearly even lower in the pecking order than I was, so the power differential was already there, and you know what’s crazy is the amount of guilt that you feel, even then, even then I remember, I was like, “God, this is not… “What am I…? I can’t help myself.” And then you’re getting bullied at the same time, so it’s like this constant… But yeah, it really did affect me, I remember, and there’s no support in those days. It’s just like, that’s just school. That’s just what you do. Yeah, so it’s really interesting. I think it is an important molding too of who you are as an adult.

– [Rachel] Right, right, bullies bully because they’re not okay.

– [Zubin] Uh huh.

– [Rachel] Right, bullies bully because-

– [Zubin] That’s pretty clear, yeah.

– [Rachel] They’re not okay.

– [Zubin] Yeah, yeah, yeah.

– [Rachel] So in my mind, we have this something, something set up, where the kids who are bullies and the kids who are not okay, we help them to be okay, and we set up a system to do that, because everyone in the school, every child, every teacher, every principal, knows the kids that are not okay. I’m just going to say that loud and clear. We know, and again, I am not saying that all those kids are mentally ill and I’m not saying they’re school shooters, and I’m not saying there’s nothing wrong with them. I am saying there’s something emotionally happening. Let’s take care of them. This compassion thing, let’s elevate that.

– [Zubin] Well, plus it breaks a cycle, because that child, ’cause most kids do not grow up to be school shooters.

– [Rachel] True.

– [Zubin] Right, but they do grow up to perpetuate the same cycle of abuse, violence, alienation, et cetera, in their own families, and the adverse childhood experiences also lead to chronic disease, and so this is a cost to society, it’s a cost of future generations, and if we intervene now, heaven forbid, we might prevent that cost, instead of having to manage the consequences of funerals, and ICU is full with people with diabetes.

– [Rachel] Yeah, and I can only imagine the red flags that the parents were seeing at home, and I don’t want to minimize actually the role of parents, because I get a kid for an hour a week. Parents are my boots on the ground. Parents are with kids all day, every day, and teachers, by the way, also are our boots on the ground, and I think we need more education in our education system.

– [Zubin] And more resources, yeah.

– [Rachel] Yeah, and more resources for what looks unhealthy to the point of we really should call 911 and not be casual about it, like the drawings that we saw and the words that we saw in the paper, the thoughts won’t stop, please help me.

– [Zubin] Yeah, man, that’s horrible. That’s bad.

– [Rachel] We could talk about this forever but-

– [Zubin] We’ve gone for 30 minutes on it. I love it.

– [Rachel] ‘Cause it’s compelling and it’s like…

– [Zubin] It’s not just about school shooters, right?

– [Rachel] Of course not.

– [Zubin] It’s about everything. So can I tell a story again?

– [Rachel] Oh, please, I love stories.

– [Zubin] I don’t know how many of these questions we’ll get to, maybe we’ll just do a three-hour interview, but the… We’ll go full Rogan, right? I just talked to a physician yesterday, a pediatrician, who was filling me in on what’s going on with COVID in kids, and the first thing I asked is, “Are you seeing ICU is full of COVID patients “or what’s going on?” He goes, “Nah, there’s the occasional MIS-C case. “There’s the occasional kid who’s got co-morbidities “who’s on a ventilator, and we all flip out over it, “because in pediatrics actually, “we don’t see that stuff that often, “because generally childhood vaccines prevent a lot “of stuff, and it’s just not that common, “so it’s a big deal when we see an MIS-C “and it gets really, fully explored. “But what I am seeing, “that people are not talking about enough, “is an epidemic of anxiety, depression, suicidality, ADHD, “or ADD, because the kids are just, they’re so isolated, “the social fabric has been so torn, “their routines have been decimated, “they’re seeing their parent’s routines decimated. “The parents are now at home when they weren’t at home “or they’re gone or whatever it is,” and then he said, and I’m going to tell you this story, not to burden you, but just because I think it’s important, my own son is X in high school and has been… And these are high functioning parents, smartest of the smart, super trained at high-end elite institutions, and this kid is super smart, but is having all kinds of struggle, like mental breakdown, because they’ve changed the structure of school to where the assignments are now due virtually by midnight, so the kid will push up until 11:59 and lose his mind and realize it’s not gonna happen, and the depression and the anxiety and his friends are… And so they went to a teacher and said, “We need to talk about this,” and the teacher was so overwhelmed, and it turns out teacher themselves has a kid in the school that’s struggling, and it just becomes this really difficult cycle, and COVID has made it infinitely more difficult. Are you actually seeing this stuff in your practice now?

– [Rachel] Kids being overwhelmed and anxious and depressed and suicidal? Oh, yeah. Oh yeah.

– [Zubin] More than before?

– [Rachel] More than before, yeah. You and I touched on this. The pediatric mental health crisis is real. Anxiety contagion is real. The adults have all been whipped up into a state of anxious frenzy by the very melodramatic media, and anxiety contagion is adaptive. When people around you are anxious and panicking, children are gonna be anxious and panicking too, and that goes back to that thing where if you’re a hunter on the plain and there’s a lion coming, and everyone around you is panicking and screaming and running, and you’re just sitting there like, you’re gonna get eaten, but if your brain develops a mechanism to take that anxiety and run with it, literally, your life will be saved. So anxiety contagion is real. Our kids are all panicking. It’s affecting their physical health, their emotional health across the board. There’s lethargy and lack of motivation and now we’ve got screen addiction times four billion. It’s really hard to be a kid right now.

– [Zubin] It really is, and I think, again, the screen addiction and the technology piece can not be overstated as a thing.

– [Rachel] No, it’s bad.

– [Zubin] We’ve talked about this before, but it’s interesting. That school shooting question had all the things that we largely answered, like how do we encourage children to think lovingly about other children, even those they don’t like? Really, you have to have a kind of a compassion, where you’re able to put yourselves in their position and inhabit it.

– [Rachel] That’s right.

– [Zubin] And there are ways to actually even have unconditional love, regardless of circumstance, but those are very difficult and advanced techniques that even adults have a lot of trouble with. So I think kids, the empathy piece is key, and then, what are better ways of addressing bullying? We talked about that.

– [Rachel] And also why aren’t we teaching all the classes we have in school, like American history and chemistry-

– [Zubin] Sociology, whatever that is.

– [Rachel] Why aren’t we teaching-?

– [Zubin] Or social studies?

– [Rachel] Can we teach emotions?

– [Zubin] Oh, so they do at my kids’ school. They do.

– [Rachel] That’s amazing.

– [Zubin] They’re teaching it in elementary school. They learn these songs about how to recognize and name their emotions before they act out on them, crazy stuff.

– [Rachel] Can we give them a gold star? What amazing school?

– [Zubin] It’s a public school in the Bay area.

– [Rachel] That’s phenomenal.

– [Zubin] And what’s interesting is my youngest daughter, the 10 year old, comes home and says, “Yeah, they’re teaching us this emotional…” I forget what they called it. Emotional IQ or something. There was a name for it, and so we sing the song about… ♪ When I’m angry ♪ And I was like, hey, that’s not bad. That’s kinda catchy.

– [Rachel] Wait, can I hear the when I’m angry song?

– [Zubin] I don’t remember it. Yeah, it was so catchy, I forgot it, ’cause I was like, if this gets stuck in my head, it’s going to be there all day. Yeah, she’ll sing it, and it is interesting, because I see her actually utilize it. She’ll say, “Daddy, are you frustrated? “Daddy, are you this?” And I’m like, “Yeah, actually, that’s really good.”

– [Rachel] So she’s helping you name your emotions?

– [Zubin] Oh my God, and I need it.

– [Rachel] So that’s my model for a beautiful future, is kids having an emotional, an EQ, a high emotional IQ, where they’re in touch with their… I know I sound like such a therapist, but understanding your own emotions and understanding other people’s emotions is critical for life.

– [Zubin] Yes, I agree.

– [Rachel] It’s critical for social interaction. It’s critical for success. It’s critical if you wanna go into business or medicine. You have to understand your emotions and other people’s emotions. It’s critical even if you want to be a podcast host. All the things are important. You have to know what’s resonant for your audience. You have to be able to read the person across from you. Emotional intelligence is so… It helps you identify school shooters. All the things are important if we’re going to be successful human beings. So how do you teach emotions to kids? Someone asked that. That was one of our questions from one of the Zdogg, from one of the Z-Pac, I believe.

– [Zubin] Yes, you’re right.

– [Rachel] How do you teach emotions to kids? It sounds like you’re doing it very successfully.

– [Zubin] The kids are getting it in school. I don’t know the exact plan they’re using, and then I talk to them about emotion too, because as an adult, I’m learning about emotion.

– [Rachel] Sure, of course.

– [Zubin] And can I tell a quick story?

– [Rachel] Please, what are we here for?

– [Zubin] We’re here to just chillax. That’s apparently what the 90’s kids said. It’s tight, bro, we’re just chillaxing. So I’ve been doing excessive amounts of meditation the last few weeks, since I came back from this retreat, and you get this assumption that meditation somehow generates equanimity and emotional regulation and allows you to just be all joy and unicorn farts.

– [Rachel] Mm, not my experience of meditating.

– [Zubin] Exactly, so what I found is, and I, again, there’s a lot of meditation, where it’s disidentifying from thought and just really silencing the thinking mind. Well, what’s underneath the thinking mind? The emotional intuitive mind, and it turns out, the thinking mind loves to repress emotion. We’re conditioned to do it from we’re very young, and we repress, deny, project, we do all these things. Doctors are very good at that. In fact, it’s a part of our training almost to compartmentalize and repress emotion, ’cause how do you get through the day? So what happens when you do a lot of meditation, or even a little meditation, is sometimes those safety valves come off and the tea kettle just is allowed to pop open, and it comes in a way that is often surprising and can generate the contralateral emotion of shame, because you’re like, I thought I was supposed to be in control. So this happened to me the other day. I was driving home, I just done a show on zen or something, and I was driving home, and I stop at a stop sign in my own neighborhood. It’s a four way, it’s a very sleepy little bedroom community, and there’s a blue Tesla pulls up to the stop sign in front of me. Now, I don’t know if I told this story on my other podcast, but at this point, I’ve got my blinker on and I was actually being quite mindful. I was like, oh, I pulled up to the… I have the right of way, ’cause I arrived at the sign first, so I’m going to make my left, this guy’s going to go straight. Well, I make my left and he then decides to go, but he stops, ’cause he sees me going, I’m halfway through the intersection, and he lays on the horn. That’s an older guy with a family of four people in there, just lays on it.

– [Rachel] And you’re like, “I’ve just been meditating, bruh.”

– [Zubin] This is what happened. Instant, primal rage comes through me. I was very close to opening the door and getting out and getting in his face, that’s how bad it was. I was entertaining the idea instantly, but what I did do was I stopped-

– [Rachel] Passive homicidal ideation.

– [Zubin] Passive, that’s exactly, when you brought it up earlier, I was like, this is me. This is me the other day.

– [Rachel] “I’m gonna throttle that guy.”

– [Zubin] I’m totally going to kill this guy, and so what ended up happening was I stopped in the intersection where I was, I rolled… This took premeditation, but the emotion was instant. I felt it. I was quite mindful of it. Rolled down the window and just stick my middle finger out the window and yell, “F you, you effing piece of F,” and this is my own neighborhood. You don’t shit in your own nest, and I was like, roll back up the window and continue with my left turn and go home, and I just look out of the… I see them and they’re just like-

– [Rachel] “Yo, is he following me?”

– [Zubin] And he just looked stunned, like what just happened? And I drove home with no anger residual at all. It had all tea-kettled out.

– [Rachel] You tea-kettled.

– [Zubin] I tea-kettled out, but this is what ended up happening. Immediately, I felt shame. I was like, I’m better than this. I just road rage on an old guy.

– [Rachel] “I’m a bad person.”

– [Zubin] Who’s just dumb and doesn’t know how to drive. That’s what I was thinking, right? And so I went and I confessed to my wife and my daughter. I was like, this is what happened.

– [Rachel] “I am a bad person.”

– [Zubin] And they shamed the crap out of me. They were like, “Aren’t you meditating four hours a day? “Aren’t you doing this?”

– [Rachel] As if that’s like a panacea.

– [Zubin] Exactly.

– [Rachel] That’s not how it works.

– [Zubin] And so then I felt appropriate. In fact, I told them because I wanted them to punish me a little bit. I was like, come on.

– [Rachel] Zubin.

– [Zubin] And so then I text…

– [Rachel] Everyone does dumb shit. You know that, yeah?

– [Zubin] I do. I kind of do, but-

– [Rachel] There’s not a single human.

– [Zubin] But I did inhabit the shame, and so then what happened was I texted my teacher in meditation and said, “This happened to me.” And he goes, “Oh.” He goes, “This is a thing that nobody talks about “in meditative spiritual circles, “that you come in contact with raw primal emotion.”

– [Rachel] Of course.

– [Zubin] “And it will shock and surprise you, “you’ll wonder where it came from, “and the best you can do is not act on it, “which is something you’ll do, because you have equanimity, “you just don’t know it, “and the best thing is to just let it pass, “feel it and then not cling to it.”

– [Rachel] You have to feel the feeling.

– [Zubin] You feel it.

– [Rachel] You have to feel the feeling.

– [Zubin] You don’t repress it. You don’t tell stories about it. You don’t-

– [Rachel] Ignore it.

– [Zubin] Ignore it. If you ignore it, it’s there forever.

– [Rachel] Bad.

– [Zubin] So I’m curious what you think about this.

– [Rachel] So many thoughts. I had so many thoughts. I hope I even remember what they all were. First thought was good that you tea-kettled. Yelling and flipping the bird is so much better… There are things like that that happened in Oakland, where someone takes out a gun and shoots someone in the head.

– [Zubin] Absolutely, if I had a gun there, could you imagine?

– [Rachel] You would not have done it.

– [Zubin] I wouldn’t have done it.

– [Rachel] You would not have done it.

– [Zubin] But you could imagine if it’s easy, right, with impulse control issues.

– [Rachel] I would humbly submit that even if you had had a gun in your car, you would have not come even close to even pointing it.

– [Zubin] Yeah, that’s true.

– [Rachel] Because your prefrontal cortex,

– [Zubin] Yeah, it still works.

– [Rachel] which controls your impulses works very well.

– [Zubin] Almost too well, yeah.

– [Rachel] Right, guess what 15 year old boys don’t have?

– [Zubin] A developed prefrontal cortex. They don’t develop until they’re 20s.

– [Rachel] This is great. We’re just gonna go full circle all day with how all the things are biopsychosocial. When you’re 15 and you’re given a gun by your parents, and I’m just going to say this, unilaterally, no parents should give a 15 year old a gun without major restrictions and controls.

– [Zubin] Training, yeah.

– [Rachel] Training and education on how to use it and when not to use it, period, end of sentence, and guns should always be locked up in the home, always, because, I think it was something like 75% of the guns used in these school shootings came directly from the home or were given by a parent. So we just have to be careful because, back to this 15 year old who have such intense compassion for it, even if there’s something going on there, his prefrontal cortex was not even yet developed. Did he have a shot at making the right decision? Yes. Did he have a shot at making the best decision possible if he had been an adult? No, ’cause he’s a 15 year old child, and his prefrontal cortex is not yet fully developed, so the odds were stacked given everything else going on. Also, you throw that into the biopsychosocial puzzle that part of your brain that prevents you from getting out of your car and punching some a-hole in the face.

– [Zubin] Poor old guy.

– [Rachel] Some poor old guy.

– [Zubin] He wasn’t that old.

– [Rachel] Who’s laying on his horn.

– [Zubin] He was like 50. I consider that old, I’m 48.

– [Rachel] Hey, watch out.

– [Zubin] Like this old fart.

– [Rachel] Yeah, watch out.

– [Zubin] Honking at me, yeah.

– [Rachel] Look, everyone’s allowed to get angry. Everyone’s allowed to express anger. This is a pet peeve of mine, that people think, in our culture, you’re not allowed to express anger. F yeah, you are. You have to. Anger is one of those emotions. If you don’t express it, it’s going to live in your body and fester and you’re gonna get physically ill. We all know that. We get stomach aches and backaches and all that crap.

– [Zubin] Sleep disturbances.

– [Rachel] Sleep disturbances when you don’t express anger, but there’s healthy ways of expressing anger. You can use your words. You can go rip phone books. You can go punch a punching bag. You can go for a run until you’re so tired you can’t get up. You could take a hot shower or a cold bath. There’s lots of ways of tea-kettling when you’re angry. But to say to people, you can’t express it, mm-mm, so bad. God, so many other thoughts too. But what I like about it is that then you came home, we’re talking about how to teach emotions to kids, you then came home to your two lovely daughters and you gave them a situ, you modeled and you labeled. Modeling is when you give an example of how you felt an emotion and expressed it, and labeling is when you put words on the emotions. So you said, “I was driving along. “This tool bag started honking at me and it triggered “in me anger and rage, “and here’s what I did that I shouldn’t have done.” But so you modeled the whole thing. You modeled the emotions you felt, and you said, “And now, I’m feeling shame and regret, “and I’m feeling bad.” So you did a perfect modeling of how certain emotions are normally and naturally associated with certain situations, and then the other emotions that follow, when you handle a certain situation in a certain way. That is emotional modeling. You just did the thing that I wrote down to talk about.

– [Zubin] Oh, wow.

– [Rachel] Yeah.

– [Zubin] Look at that. It’s like we’re like-

– [Rachel] Psychically linked.

– [Zubin] Exactly, those two guys from “G.I. Joe” Tomax and Xamot, who were twins and they shared a psychic connection. You’re welcome, and by the way, Tomax is Xamot spelled backwards.

– [Rachel] Oh my God.

– [Zubin] Hey.

– [Rachel] “G.I. Joe” just entered the conversation.

– [Zubin] Now you know, and knowing is half the battle. Another “G.I.”

– [Rachel] I used to watch that when I was kid with my brother.

– [Zubin] Cobra.

– [Rachel] “G.I. Joe.”

– [Zubin] I used to like Cobra Commander, because he was the same voice that did Starscream from “The Transformers.” He was like, “Yes, Destro, it’s Cobra Commander. “G.I Joe is coming.” And Destro was like, “Cobra Commander.” He talked like James Earl Jones.

– [Rachel] It’s delightful.

– [Zubin] It’s a whole thing.

– [Rachel] Oh God, I’m so delighted. Now, I just want to do voices.

– [Zubin] We could do that for the rest of the-

– [Rachel] Did you also watch… God, the lion, what were those lions?

– [Both] “ThunderCats.”

– [Zubin] Dude, not only did I watch “ThunderCats,” I started rewatching it with my youngest because we would just laugh at how stupid it was.

– [Rachel] I loved it.

– [Zubin] You know, thunder, thunder, thunder, ThunderCats, ho, all right, and there’s…

– [Rachel] It’s the best.

– [Zubin] And there’s the lion, and you hear… And they turn into… And they had Mumm-Ra. “Ancient spirits of evil-“

– [Rachel] I was terrified of Mumm-Ra.

– [Zubin] He’s a scary dude. He’s lived thousands of year.

– [Rachel] He’s like a walking…

– [Zubin] Pharaoh mummy.

– [Rachel] Scabby mummy, terrifying.

– [Zubin] And he prays to the ancient spirits of evils.

– [Rachel] And there’s all drool coming out of his mouth.

– [Zubin] Oh, yeah.

– [Rachel] It’s very scary.

– [Zubin] ‘Cause he’s like… And Snarf, the little strange-

– [Rachel] Snarf, Snarf.

– [Zubin] Snarf, talk about someone who got bullied.

– [Rachel] Oh, Snarf.

– [Zubin] We have to really heart out for Snarf. Snarf had a lot of adverse Snarf experiences as a child.

– [Rachel] It’s true, but he never grabbed a gun and shot other ThunderCats.

– [Zubin] Because they wouldn’t let him.

– [Rachel] Because he had community.

– [Zubin] Lion-O-

– [Rachel] Social support.

– [Zubin] He had social support with the cats.

– [Rachel] See, social.

– [Zubin] Lion-O would always keep his Sword of Omens locked up. He taught Cheetara, the female thing and the two kids, Lioncat and Lionkitty, whatever.

– [Rachel] No, it literally has been so long for me.

– [Zubin] They learned weaponry from the best, and safety, responsible use of weapons, didn’t ban the weapons, said, “Listen, here’s how you use the Sword of Omens.” “Okay, you’ve got to say ho at the end and never…” It’s something about trigger hygiene.

– [Rachel] You’ve gotta say ho at the end.

– [Zubin] You’ve gotta say ho at the end. If you say ho at the beginning, you can put an eye out. The thing grows.

– [Rachel] At the end of this, we have to say ho.

– [Zubin] That’s right, dude. I’ll go ho. That’s right. Amazing, amazing.

– [Rachel] Oh my God.

– [Zubin] This is a perfect segue into the next question.

– [Rachel] It really is.

– [Zubin] Because this is good.

– [Rachel] It really is.

– [Zubin] Because we’re giggling like we’re on marijuana.

– [Rachel] Oh my God. Yeah, right?

– [Zubin] And this is a question from our… And this is a good one.

– [Rachel] As if we’re high.

– [Zubin] Exactly.

– [Rachel] But we’re not. Sober, totally sober.

– [Zubin] But we’re not. Marijuana for pain. Is that a thing? Can you talk about marijuana for pain? I hear such mixed things. Even my parents have tried it. Helpful for pain. Yes or no? Via Twitter.

– [Rachel] Helpful for pain?

– [Zubin] Sam via Twitter.

– [Rachel] Yes or no. Okay, so we’ve talked about the fact that I am a pain doctor and I am fascinated by pain, because it is a ubiquitous human experience and none of us will escape having pain at some point in our lives if we don’t have it now, and pain has been grossly mistreated for many decades. We have framed it as a biomedical problem. So what I mean by that is just to do with the body and you treat that thing with pills and procedures primarily, if not exclusively, but what has happened? Again, chronic pain is on the rise. We have an opioid epidemic. People in pain are not getting better. Most people in pain will tell you that they have been in pain for 20 or 30 years without respite. It’s pretty bad. So we are always understandably, and myself included, looking for a quick fix. Who does not want a fix from pain? Pain is miserable. Pain hurts, which is a profound obvious statement.

– [Zubin] Yeah, and yet, pain hurts. Hurts implies the suffering component of pain, pain itself, the raw experience, so I think it’s actually not as obvious as it sounds, yeah.

– [Rachel] Thank you. You just took it another level and… No, no, no, but in a really, really good way, and thank you for that.

– [Zubin] Mm, why, thank you.

– [Rachel] That is right. The suffering component of pain is not to be overlooked. So I have so many things to say about pain, but I’m going to hold myself back because I will get so far off subject that we won’t answer this question.

– [Zubin] The Mary Jane.

– [Rachel] So when I was an undergrad at Brown, I worked with this very cool guy, J. Michael Walker, and his-

– [Zubin] God, that name is so awesome.

– [Both] J. Michael Walker.

– [Zubin] Professor at Brown, how are you, ladies?

– [Rachel] Yep, he studied the neuroscience and neurophysiology of pain, and I wrote my honors thesis with him.

– [Zubin] Wow.

– [Rachel] And he was, may he rest in peace, a total pot head, absolutely, long beard, fish head, Grateful Dead.

– [Zubin] Nice.

– [Rachel] Super nice and brilliant guy, and he was studying, specifically, bear with me, this is really obnoxious nerdy language, anandamide, which is an endogenous cannabinoid, endogenous cannabinoid. What I mean by that is your brain already produces the chemicals that are found in marijuana. That’s why marijuana works when you eat it or smoke it, because the cannabinoids bind to the receptors that already exist in your brain. That’s the mechanism of action, and that’s why they work. So his research was endogenous cannabinoids, again, those cannabis-like substances that already exist in your brain, what do they do for pain? That was his research question. Right, so he would use hot plate tests, which is very ethically dubious, where you put mice on hot plates and you raise the temperature, and if they have high levels of endogenous cannabinoids, will they stay on the hot plate longer? Will they be able to tolerate pain longer?

– [Zubin] Higher pain threshold. PETA’s going to pay J. Michael Walker a visit.

– [Rachel] He is no longer with us, and studies like that actually are done fairly regularly, I think.

– [Zubin] Regularly.

– [Rachel] Yes.

– [Zubin] You know who else isn’t with us? Jan-Michael Vincent.

– [Rachel] Mm, why?

– [Zubin] I believe he died, but not before producing probably the greatest drama of the 80s, “Airwolf.”

– [Rachel] Okay, miss it.

– [Zubin] As Stringfellow Hawke. You missed “Airwolf?”

– [Rachel] I did, sorry. Don’t fire me.

– [Zubin] You know what? I’m going to put you on a hot plate and slowly raise the temperature and force you to watch “Airwolf.”

– [Rachel] No, I decline that invitation.

– [Zubin] All right, well, that’s okay.

– [Rachel] I’m sorry, I’m not going to do that.

– [Zubin] So back to this ethically dubious experiment with the mice.

– [Rachel] So for my many years of training in pain, one of the things I’ve always been curious about is endogenous cannabinoids, those things that your brain already produces. By the way, we also have endogenous self-made opioids, those are called endorphins, so if you go for a runner’s high or you have a runner’s high, those are your endorphins. So our brain produces all sorts of pain regulation chemicals already, but I’ve been doing a ton of reading about marijuana and other sorts of cannabinoids for pain, and I always, literally, until this week, was under the impression that the research supported that marijuana and derivatives, cannabinoid-like substances, could ease pain.

– [Zubin] Hmm, now, before you give me the punchline of this, what did J. Michael Walker’s mice end up showing with the-

– [Rachel] Higher pain tolerance.

– Ah, so it did, with cannabinoids.

– [Rachel] Correct.

– [Zubin] Okay, all right.

– [Rachel] That’s my memory, and I’d have to go back.

– [Zubin] In mice.

– [Rachel] These are research papers from a long time ago, and I don’t know if other things have been shown since then. Before the punchline, what has your impression been…

– [Zubin] Correct.

– [Rachel] About this whole marijuana for pain?

– [Zubin] Correct, so I did, and by the way, I’m an advocate for legalizing pretty much everything, I did a piece on this a few years back, and it was looking at the evidence basis based on James McCormick’s work in University of British Columbia, where he reviewed all the literature that looked high quality on cannabis and the like, and what he found was there were three real indications that were evidence-based. One was spasticity from multiple sclerosis.

– [Rachel] Right, I’ve heard that too.

– [Zubin] Definitely. The second was pediatric seizure stuff.

– [Rachel] Also heard that.

– [Zubin] Which we have now a pharmaceutical derived cannabinoids for that. The third thing was chemotherapy-induced nausea, and the fourth thing actually, ’cause this was another thing, was they said chronic pain from neurogenic origin, neuropathic pain typically, and there’s some evidence, but the evidence was based on a synthetic cannabinoid they were giving them, was eaten, that was not smoked. It was not natural cannabis. So that was what I talked about in those things. Everything else, like anxiety, all those other things, it did not look like it helped at all from the literature.

– [Rachel] Were you ever in a position where you could prescribe it?

– [Zubin] Yeah, I was asked to prescribe it and then it became largely legal in California, even before that, for medical purposes, so people have occasionally asked me, and I’m not averse to it, but I would have a conversation with them and say, well, so what are we really doing this for?

– [Rachel] What are we treating?

– [Zubin] Because you have to be careful with the right indication for it.

– [Rachel] Sure.

– [Zubin] Yeah, so I believe I have done it at least once or twice, years ago.

– [Rachel] Yeah.

– [Zubin] Yeah.

– [Rachel] Yeah, I am also, by the way, I am also not opposed. My thought about pain and pain medicine and everything to do with pain is like if it works, let’s use it.

– [Zubin] Oh, by all means. Even if it’s placebo, I’m happy, if it doesn’t cause harm.

– [Rachel] Placebo all day.

– [Zubin] All day.

– [Rachel] Please give me a placebo pill.

– [Zubin] Me too.

– [Rachel] God, please.

– [Zubin] Give it to me IV.

– [Rachel] Oh, yeah.

– [Zubin] I’ll snort placebo.

– [Rachel] Oh, we should talk about placebo one day. You know that there’s this study that shows that you have these people randomized to these groups where they think they’re getting knee surgery, they’re actually getting knee surgery or… I can’t remember what the third one is.

– [Zubin] Yeah, I forgot. It’s like nothing or they pretend to cut the skin. I don’t know what it was.

– [Rachel] Yeah.

– [Zubin] It’s like a sham surgery.

– [Rachel] They actually cut it. Yeah, they actually cut it, but they blow air into it and then seal it back, and the people who thought they got surgery, I think they performed even better than the people who got the actual surgery.

– [Zubin] ‘Cause they didn’t have all the complications, right?

– [Rachel] Anyway, just to say, I want placebo all day.

– [Zubin] All day.

– [Rachel] So a study came out in July 2021, so this year, just a few months ago, about the effectiveness of marijuana cannabinoids and everything to do with cannabis for pain and the summary, which I’m going to read, just because reading.

– [Zubin] So it was a meta analysis of-

– [Rachel] It was a meta analysis of all the things, and what they said was that there is currently no reliable evidence to support the use of cannabis, cannabinoids or cannabis-based medicine in the treatment of chronic, acute or cancer pain, and that medical marijuana and associated cannabinoids can cause significant secondary issues with sleep and memory and attention and problem solving skills, and I think any of us who have ever smoked before know that sometimes sleep and attention and problem-solving do fall by the wayside, and of course, when it comes to pain, we’re not talking about sitting around smoking a joint, there are different forms of cannabis, the THC has been removed.

– [Zubin] The CBD forms, and there’s edible and smoked. There’s different, first pass metabolism or not. There’s all kinds of metabolic vagaries around it, which is why these studies are difficult too.

– [Rachel] Exactly right.

– [Zubin] Yeah, their studies are difficult. Yeah, I think this is really interesting. It’s unsurprising to me, but it’s also something where I would never, and I think you agree with me, I would never say, well, hey, if you find that cannabis works for your pain, stop using it.

– [Rachel] No, I would never say that.

– [Zubin] Never, because it’s like, hey, it works for you. That’s great.

– [Rachel] If it works for you, work it.

– [Zubin] Absolutely. Maybe it’s something that science has missed. Maybe it’s a placebo effect. Who cares?

– [Rachel] Maybe it’s the chemistry of your unique brain and body.

– [Zubin] Can I tell you a theory I have-

– [Rachel] Yes.

– [Zubin] That is total BS but I’ll tell it to you? So I had this guy, Donald Hoffman, on the show, who his theory is that he’s a cognitive scientist at UC, Irvine, and a psychology professor as well, and he studies AI in different things, and his theory is that humans don’t see reality. We see an interface, like a graphical user interface, that is species specific, it’s evolutionary, and it evolved not to show us the truth of the world, but to show us a dumbed down symbolry that represents fitness payoffs, meaning I’m very likely to eat that and do well, I’m very likely to have sex with that and reproduce, and so we see this matrix like that. So that interface is pointing at a real reality. There’s something out there. He says it’s all these conscious agents interacting. Who cares, right? The bottom line is we all have our interface. Within the species, there’s variation in the interface, so some people see things, like some people can have synesthesia and can actually smell colors and things like that. Those are mutations in our graphical user interface, and he calls it the interface theory of perception, and there’s a lot of data. He has a whole book on it called “The Case Against Reality.” Now, what I suspect is, and from my own personal experience with these things, is that people who their baseline interface tends to the more paranoid, the slightly more anxious, the slightly more unsettled in a baseline state can take a compound like a cannabinoid and shift their interface, that’s what these drugs may do in this theory, shift their interface a couple clicks to the right, where now what used to make them a little unhappy or uncomfortable or anxious is now much more okay, and they see the world through this different interface. You and I may take that with a different baseline interface and get more paranoid, anxious, unhappy, and wonder how that person can smoke weed all day, every day, and so these variations in our own personal interfaces, which are the complex biopsychosocial interaction of us in the world, whatever that means, manifest different things. That’s why I would never tell somebody, hey, if that works for you, don’t.

– [Rachel] Oh, I totally agree. I totally agree. It really threw me for a loop though to read this, because for many years, I was laboring under the impression that when used correctly in particular doses or forms, that cannabis could be an effective treatment for pain across the board, and reading that the studies did not support that really shook me, but I agree with you 100% that… So can I tell you a story?

– [Zubin] Yes, please.

– [Rachel] Okay, so a couple of years ago, and I’m changing the identifying information on my patients.

– [Zubin] Please.

– [Rachel] Of course, to protect identity, because that is how I roll. So a 26 year old young adult, let’s call him Sam, came to my office with a condition called Fabry disease.

– [Zubin] Hmm, I’ve heard of that. I forget what it is. Fabry disease.

– [Rachel] Do you remember anything of it?

– [Zubin] F-A-B-R-Y?

– [Rachel] F-A-B-R-Y.

– [Zubin] Yeah, I don’t remember.

– [Rachel] Yeah, well, the gist of it is it’s a genetic condition and it leads to pretty serious peripheral neuropathy, in the feet in particular, and this 26 year old came wheeled into my office in a wheelchair, and his body language told me he was depressed, hunched over, his face looked completely stricken and depressed. His toenails had not been cut in something like eight months or more, and they were very long, almost claw-like, and his feet were bare, and the peripheral neuropathy, the pain of his feet was so intense that he couldn’t even put his feet on the… What are they?

– [Zubin] The little thing at the bottom of the exam table?

– [Rachel] No, on the wheelchair. There’s like the little pedals.

– [Zubin] Oh, yeah, the little supports.

– [Rachel] Or supports or whatever. So he had like-

– [Zubin] Foot rest.

– [Rachel] That’s what I was thinking.

– [Zubin] Word finding difficulties.

– [Rachel] I know.

– [Zubin] Cannabis.

– [Rachel] We’re both high.

– [Zubin] Yeah.

– [Rachel] Obviously. So he had cushioned slippers or something at the very bottom, or they had pasted the slippers to the foot rest or something. To be clear, this was a kid who was not okay. He was not okay. He was miserable. He hadn’t been able to… A college student, who’d not been able to attend college. He had a lot of hobbies. He couldn’t engage in any hobbies. He couldn’t walk. He was wheelchair bound. His parents had tried everything for his pain. Like as often happens, I was the last stop on the train, because as you well know, nobody with pain wants to see a psychologist for pain, because we have framed pain as a purely biological, biomedical problem, and who is going to see a psychologist for a biomedical problem? That just suggests that maybe your pain is all in your head or you’re mentally ill, and of course, that’s not what it is. Pain is a biopsychosocial problem. It requires a biopsychosocial solution, and a pain psychologist like me looks at the whole biopsychosocial problem, and it’s like, okay, what are the things we need to change in all of these domains to treat you as a whole person? ‘Cause you’re not just your feet, and so far, treating just your feet isn’t actually working. So just to say. Okay, so he had been in this wheelchair for a couple of years. He had not been able to walk. His toenails were really long and claw-like. He was hunched over. He had really bad acne. He wasn’t seeing friends. He wasn’t going to school. He wasn’t eating very well. He had no life. One of the things his parents had decided recently to try for his pain were CBD gummies, and again, let me just say, all in. You’ve got a kid in a chair. Nothing’s working. I am all in. Let’s try all the things. Here’s what happened with the CBD gummies. He would take a gummy and it would make him sleepy, a little foggy, and he would go take a nap on the couch, and when he woke up, no pain.

– [Zubin] What?

– [Rachel] And he would go for a walk and sometimes get on his bike and bike around and go to the corner store and pick up some candy and come home and hang out with his brother, and then it would wear off, and we’re back at ground zero, and this happened for a couple of weeks, and I was like, something very interesting is happening here.

– [Zubin] Yeah.

– [Rachel] So the parents said to me, “We want to try and experiment with your support. “We are wondering what would happen…” And I know this is controversial and I just want to say it was not my idea. “We want to know what would happen…” Do you know where I’m going with this out of curiosity?

– [Zubin] No.

– [Rachel] No idea? Oh. “If we replaced his CBD gummies with regular gummy bears.”

– [Zubin] Oh, wow.

– [Rachel] And I said-

– [Zubin] This is the experiment, yeah.

– [Rachel] I cannot tell you to do this or to not do this. You are the parents and you are in charge. However, if you do it, please let me know what happens, because wow, isn’t that fascinating?

– [Zubin] Yeah, right, so going from treatment arm to placebo arm without telling patient, seeing what happens, and what happened? I’m on pins and needles.

– [Rachel] The next day, they gave him a cherry, regular, non-CBD gummy bear, just delicious cherry gummy bear. He got sleepy. He went for a nap on the couch. When he woke up, he had no pain. He went for a walk. He went for a bike ride. He went to the corner store. He bought some candy. He came back and when it wore off, he could no longer walk and was back in his wheelchair, and we did that for about three weeks, and I think his parents eventually told him, and the interesting thing was is it was that experiment that his parents decided to pull, and please don’t get mad at me. This is not my experiment. I did not suggest it, but people are like, “That’s so mean of parents to do to a kid.” Listen, parents tell their children that Santa is real.

– [Zubin] And then pull the rug out later.

– [Rachel] Parents lie to kids all the time, just to say, so let’s be careful with getting so angry about that. Tooth fairies and everything.

– [Zubin] This is a 26 year old.

– [Rachel] And I would much rather… Right, but the 26 year old adult child of these parents, and I would much rather lie in a capacity that saves a kid’s life or an human adult’s life, than in a capacity where I’m lying about Santa Claus. So if we’re going to be okay with white lies, let’s go with this one. That’s just my humble opinion and people will disagree with me and that’s okay. I was able to use that example in our clinical work as evidence for him that pain lives in the brain, not in your feet, and that your brain is constantly trying to decide whether or not to make pain and to protect you, based on all available information, whether or not I’m safe, what my body is doing, what my social environment is like, what my context is like, and because his brain before was under the impression it needed to protect him a lot, it was really amplifying pain, but now that there’s medication in his system, his brain is calming down the pain alarm, which is exactly what the placebo effect is doing. It’s turning down the pain alarm. It’s turning down pain volume. That’s what the gummy bear was doing.

– [Zubin] So what happened after they told him that this thing was placebo?

– [Rachel] Yeah, he and I had been doing treatment together for a while. He actually knew the science behind it. The answer is he got better. He stopped using any gummies, and we did a whole protocol, like pacing. There’s a lot of protocols that we use when we’re trying to get a kid out of a wheelchair and to get their functioning back, and we did it together, and he got better and he got out of the wheelchair and back to life, and he’s okay now, and I get Christmas cards from his family all the time.

– [Zubin] That’s unbelievable.

– [Rachel] Yeah, it’s amazing, and we got him off all meds, by the way, all of them.

– [Zubin] Okay, so there’s some… Oh my God.

– [Rachel] I know, I know.

– [Zubin] This is one of those deals where I want to talk for 17 hours about every single point, but I won’t, because holy crap.

– [Rachel] No, we can’t, , I know.

– [Zubin] Yeah, so this is… Okay.

– [Rachel] And his pain was real.

– [Zubin] Yeah, oh, no, no, 100% real.

– [Rachel] And it wasn’t psychological.

– [Zubin] No, it was real pain, like you said. Pain is this whole thing.

– [Rachel] Fabry. He has Fabry disease. It’s real.

– [Zubin] Yeah, no, he has a thing.

– [Rachel] That’s right.

– [Zubin] But because pain is this complex entity, you were able to intervene in a way that was actually quite complex.

– [Rachel] Very complex.

– [Zubin] Because that intervention had a biopsychosocial component to it.

– [Rachel] It sure did.

– [Zubin] It had the expectation component, it had the chemical component, and then it had the social component of people saying, “Here you go, here’s a very powerful treatment.”

– [Rachel] Mom and dad.

– [Zubin] Mom and dad.

– [Rachel] Trust.

– [Zubin] Trust. Therapeutic relationship, you might say, therapeutic alliance, and all of that goes into making even a placebo incredibly powerful. Now, this actually has very valid repercussions in the world of everything, because when you talk about COVID and people are like, “I don’t understand. “I gave them ivermectin. “I gave them hydroxychloroquine. “They got better.” Well, okay, how much of that is just luck, but how much of that is a real placebo effect? When someone thinks they’re gonna die of a disease and you give them something that you’re like, “Everyone who I give this to gets better?” Suddenly, the mind tamps down the cortisol levels. That cytokine storm never happens that was gonna happen. The dry tinder gets moistened and it’s not going to catch on fire. This is real. That’s why it’s important to talk about randomized control trials and all of that. I think that’s very important, but it’s important we also recognize placebos and understand that that can confound our understanding of science if we don’t recognize the power of this and this and this together, and this together.

– [Rachel] Yup, if I were allowed, I’m a big believer in medical ethics, and I don’t want to suggest, but if I were allowed, and I do understand the complexities here, I would have a jar full of red-

– [Zubin] Obecalp.

– [Rachel] Placebo spelled backwards, pills or red gummy bears, don’t care, in my office, and I would say, “This is a cure for your Fabry disease. “This is a cure for your chronic migraine. “This is a cure, and I want you to take two of these a day. “Here’s what you’re gonna feel. “You’re gonna start feeling a little bit better tomorrow, “a little bit better, and then, in two weeks, “you’re going to notice this big…” I just would make up a whole story about it, and if I were allowed, I would give every one of my kids a red gummy bear, and my adults too.

– [Zubin] Because your goal is not fidelity to truth. Your goal is fidelity to suffering, and that is as valid a goal as anything.

– [Rachel] Except I would lose my license and get fired.

– [Zubin] No, you can’t do it. You can’t do it, but why?

– [Rachel] Right, that’s the shit of it.

– [Zubin] I know, that’s the shit of it, isn’t it? ‘Cause I’ve said that too. If I could prescribe placebo ethically, I would do it all day, every day, for non-fatal diseases. Even for diseases where we have no other treatment, it’s like, well, here you go, and it helps. Well, so that actually is a good segue maybe into long COVID. What do you think? You want to talk about long COVID? Just because we know so little about it, but it’s a biopsychosocial condition. Please address long COVID and the ongoing fatigue that comes with it. How do people with long COVID recover and become more normal? Not wearing masks after being vaccinated and the fear of getting it again, the trauma from having it, it’s real. I went to urgent care over 10 times, had unexplained neurological issues from COVID. Could pathogens still be in my body? Could Epstein-Barr be activated from COVID? I’m doing healthy things that have dramatically helped in my recovery, including juicing, improving my diet, calming the vagus nerve, which has gone a long way in my healing. I want to learn about CBT, cognitive behavioral therapy, as well, and how I might help me recover. Thanks for any insight. Claire, via Twitter.

– [Rachel] So let’s turn the mic over to you, Dr. Zubin, because I’ll say why I am. Watching you is how I’ve learned a lot. I read the news too, but watching you is how I’ve learned a lot about COVID and I’m curious to know what your impression of long COVID is and are you hearing a lot of this?

– [Zubin] Yes, I am, and this is what I… The best I can formulate, because the data on this is poor.

– [Rachel] Good to know.

– [Zubin] Even the criteria for discussing it are like, well, you have symptoms three months or longer, and then some people have symptoms six months and longer, and those symptoms may be something like smell loss, which we know is a biomedical component of COVID, because it affects the sustentacular support cells. The actual coronavirus can infect and destroy those, or at least cause damage to them, and those, we think now, increasing data shows that that’s probably what the source of lack of smell, and they take a while to regenerate, and some people, they may never regenerate, and that can be debilitating. So that being said, this long COVID scenario feels very similar to things like chronic Lyme, chronic fatigue syndrome, some components of fibromyalgia, in that they are biopsychosocial. There is a social component, which is real, the media component, the social expectation, “Did you know, one in five people will have long COVID,” and again, I don’t say this in a way to disparage even the media. It’s just this is the environment that people are in, the social component. We’re social animals. We imprint on these things. We have expectations, so you have that, then you have the psychological component, what she mentions in this, of the trauma of the suffering, and that’s why it seems like more severe cases of COVID are associated with a little more long COVID, but even minor cases can develop into this, and then there’s the biological component. So she’s asking about is it Epstein-Barr virus activation? Which was the speculation too, with chronic fatigue and other things. Epstein-Barr is a good punching bag for a lot of things, because when it causes mono in many young people, it causes a lot of these symptoms that people have, and one of the cardinal symptoms is actually sleep disturbance, brain fog, fatigue. So the brain fog component, the mental components of it are very difficult to explain solely biologically, which is why the medical system struggles with it, ’cause we reduce it to the quadrant of it, instead of including I, we, us and it. So that’s my take is we don’t know, but I will say this, talking to a lot of smart doctors who take care of it. They will all tell me this is biopsychosocial.

– [Rachel] Oh, great.

– [Zubin] Yeah, they get it.

– [Rachel] Oh, great.

– [Zubin] They’re like this is not easily explained with something that’s a receptor or residual virus, and here’s an interesting thing. People who get vaccinated with long COVID anecdotally feel better. Some people are actually cured. Now, why would that be? You could speculate a lot of biomedical stuff, well, there’s an immune response, there’s residual virus and it really jazzes up the immune response, but I’m not compelled by that. I’m compelled by the idea that we have a powerful therapeutic intervention that also has a biopsychosocial component, the vaccine, and it is making them feel better on multiple different levels. So that’s my take on long COVID so far. The suffering is real.

– [Rachel] Will you say on the various levels that the vaccine makes people feel better?

– [Zubin] So what I think with the vaccine, and this is speculation-

– [Rachel] And this is really fascinating for me.

– [Zubin] Speculation is that there is an expectation component that is even unconscious. So if you ask them, “Oh, did you think this vaccine was gonna make you better?” They’ll say, “No, why would it? “I’m just getting it because people tell me. “I don’t want to get reinfected. “I’ve already had COVID. “I don’t want to have it again. “If I had these symptoms again, “I’d wanna really hurt myself. “It’s not good.” But on an unconscious level, there has been all the media explanation that, hey, these are very powerful medications, and in fact, even some of the false media expectation that there are all these terrible side effects that aren’t really true, and there is the real side effect of myocarditis and all that, make the intervention seem very powerful unconsciously, and I think that then generates a biopsychosocial field of whatever it is that we don’t understand, that then interacts with whatever’s going on and makes things better.

– [Rachel] Wow.

– [Zubin] And what’s interesting is it doesn’t make it worse. We don’t see people saying, “I got worse after my vaccine.” Yeah, so there’s something going on there, and I think if we could crack long COVID, then we would crack fibromyalgia and chronic fatigue syndrome and chronic Lyme disease and a lot of different things.

– [Rachel] Right, agree that a lot of the things we’re seeing with long COVID map onto a lot of what we see with a lot of chronic illnesses, including the fatigue, including the low mood, and what’s interesting about COVID is I can’t think of an illness that has been more politicized and villainized and there’s so much shame. So I tested positive for COVID a year and a half ago now.

– [Zubin] Weak, you’re weak. You didn’t socially distance and mask enough.

– [Rachel] It was worse than weak. It was like you’re a bad person.

– [Zubin] Yeah, exactly, that’s how-

– [Rachel] You didn’t protect yourself and you didn’t protect your loved ones, and by the way, I did. I was in a pod of two people.

– [Zubin] Yeah, exactly.

– [Rachel] Including my partner.

– [Zubin] That other person was a piece of shit.

– [Rachel] Yeah, but no, they didn’t have it. No one else in my pod had it. I wore an N95 mask.

– [Zubin] Yeah, you might’ve had a false positive even.

– [Rachel] I think I did, but not even to the point. When I tested positive, the first emotion I remember feeling was shame, even before fear. Part of me was like, “I might die,” because that’s what the news is telling me, but the biggest emotion I had was shame. I am shameful. I am dirty. I am Typhoid Mary. I am ground zero for the vector.

– [Zubin] Pariah in my community.

– [Rachel] I am a pariah.

– [Zubin] High sphincter tone, Bay area.

– [Rachel] High sphincter tone, it took me a minute. Yeah, and I think that that has happened. So the illness has become stigmatized. If you have COVID, everyone wants away from you, they want nothing to do with you, and you’re a person who has infected the school or infected the plane. You’re a bad person. That’s never happened with the flu. It’s never happened with any other illness that I can think of that has some contagion.

– [Zubin] HIV, it did.

– [Rachel] That’s true. HIV became villainized.

– [Zubin] And that was a good lesson on stigma.

– [Rachel] That we didn’t learn.

– [Zubin] On how to do public health interventions-

– [Rachel] We did not learn that lesson.

– [Zubin] That work.

– [Rachel] Yeah, we didn’t learn that lesson.

– [Zubin] No, we did not.

– [Rachel] So to your point, people with long COVID are dealing with more than just the fallout of I had this virus rampaging through my system and it caused all these biological problems, but also, there’s the stigma. There’s the shame. There’s the depression. There’s the fatigue. There’s the I’m cut off from my social community, and what does that do to my health? Back to, again, people who are isolated and lonely and alone-

– [Zubin] They do worse. They do worse.

– [Rachel] Do worse.

– [Zubin] Yeah.

– [Rachel] Physically. You can engage in your hobbies. So with chronic illnesses, one of the treatments, by the way, for every chronic illness is engaging in a pacing plan.

– [Zubin] What’s that?

– [Rachel] Yeah, so for chronic pain, we have a chronic pacing for pain and fatigue plan. So what we do is when people have so much fatigue and exhaustion that they can’t get out of bed and they lay in bed, as you know, for days and weeks and sometimes months at a time, guess what happens to your mood?

– [Zubin] Down the crapper.

– [Rachel] It crashes. Guess what happens to stress and anxiety when you’ve been missing out on life and activities?

– [Zubin] Through the roof.

– [Rachel] Through the roof. Stress and anxiety spikes. We know, from all the research, that when stress and anxieties spike and mood crashes and you become depressed, physically, your prognosis is worse and pain amplifies. That is the recipe. So that’s the chronic pain recipe. It’s the chronic fatigue recipe. The do nothing plan seems reasonable, and because your body has been suffering, makes a ton of sense, and the treatment is to get your life back a teeny, teeny, tiny bit at a time, so pacing for a marathon… Have you ever run a marathon?

– [Zubin] No. The most I’ve ever run is like eight miles, and that was too much.

– [Rachel] That’s a lot.

– [Zubin] Yeah, it was too much.

– [Rachel] I did a 5K over Halloween. It was really delightful and I dressed as a monarch butterfly, which is why I have a butterfly costume.

– [Zubin] That’s amazing.

– [Rachel] It really was amazing.

– [Zubin] We are gonna get to the furry part of the show at some point.

– [Rachel] Ho.

– [Zubin] Ho. So sorry, pacing, because the ThunderCats paced themselves. Snarf was the pace car.

– [Rachel] There’s a lot of pacing required. So the way you pace for a marathon, I have never run a marathon, but I have run a 5K. I am not a runner to be clear. I’m not an athlete, but I was like, “Let me see if I can do this thing.” The way you pace is you do a little bit at a time. You figure out your baseline, and your baseline is how much can I do today without any training like, oh, I can walk for 10 minutes. That’s it. That’s what I can do, and that’s great, and you take that number and you do it every day for a week. So every day for a week, you’d go outside and you walk for 10 minutes in the sun. Now, for some people with long COVID, or any other chronic illness, their baseline is probably lower. Maybe it’s six minutes. For one of my kids, who had had chronic pain for four years, it was standing on his front porch for 10 minutes in the sun.

– [Zubin] Wow, yeah.

– [Rachel] That’s where we started. Guess what? That kid is the captain of his ultimate Frisbee team.

– [Zubin] Wow.

– [Rachel] That’s right, but where we started was, and that’s a true story, and where we started was standing on your porch for 10 minutes in the sun. So pacing plans work, and you have to figure out where you can start, and then you add on a certain amount of minutes every day, and it’s very, very important when putting together a pacing plan to have a goal, and what I mean by a goal is it can be a functional goal, like a thing you need to do, like I need to go grocery shopping, a function. It can be a pleasurable activities goal, like I love ice skating, so I’m gonna… Or fudge making. I really just want to make fudge. Or it can be like I’m an athlete and I wanna get back to running. So as long as you have a beloved valued goal at the end of the line, your pacing plan is likely to be effective. So you start somewhere. You figure out what you can do today. You add on a few minutes. If it’s fudge making, it’s like, okay, I’m going to stand in the kitchen for 10 minutes. I’m going to buy a couple of groceries, and you work your way back to life, but the do nothing plan is the opposite of what’s effective, and that’s what happens with long COVID and any chronic illness is that we languish.

– [Zubin] People just withdraw. Yeah, we withdraw.

– [Rachel] We stop moving. We stop seeing friends. We stop going outside, and COVID is so stigmatized that like, of course.

– [Zubin] This makes perfect sense. The long COVID thing is right up your alley too, ’cause this is exactly… There’s a biological component, and again, there’s lots of research I think happening. There needs to be more, but this is… In some way, we have, as a society, have made long COVID a thing and worse, and I’m not saying it’s created by that, but it is part of the dynamic in it, because there are these, and I don’t know if we’ve talked about this on previous shows, there are these precedents, in Hong Kong and elsewhere it has been studied, where a syndrome happens, say, to a young girl. It gets a lot of press and it’s maybe a fainting spell or something, and suddenly, there’s a rash of fainting spells. It actually goes back to the copycat question in the school shootings, like why does that happen? That we are social creatures and there is a social contagion that happens, and suddenly, there’s a biopsychosocial interaction with the right substrate, the right situation, the right media, the right story, and suddenly, everybody’s having syncable… They’re passing out. So this does happen.

– [Rachel] It does happen.

– [Zubin] Yeah, it does happen.

– [Rachel] I really love the way you just described that.

– [Zubin] No formal training.

– [Rachel] I think lots of formal training.

– [Zubin] You know what I have formal training in? Ho.

– [Rachel] “ThunderCats?”

– [Zubin] That’s right, “ThunderCats.”

– [Rachel] I was waiting for that. I actually knew that was coming.

– [Zubin] You knew it was coming.

– [Rachel] Yeah, I did.

– [Zubin] ‘Cause you’re Tomax and I’m Xamot.

– [Rachel] As long as I’m Tomax. I don’t want to be the backwards name.

– [Zubin] No, Xamot is too…

– [Rachel] It’s too confusing.

– [Zubin] You don’t want a name that starts with an X.

– [Rachel] Well, you might.

– [Zubin] I might ’cause I start with a Z.

– [Rachel] Yeah, that’s what I’m saying.

– [Zubin] So I’m pretty close as it is.

– [Rachel] I start with a Z too.

– [Zubin] That’s true. We’re the two Zs, Pain Points with Z and Z. Shall we do one more question?

– [Rachel] I don’t know. Should we?

– [Zubin] I think so. We’re almost coming on… We’re going to close on an hour, two hours.

– [Rachel] Two hours?

– [Zubin] Yeah.

– [Rachel] We’ve been here two hours?

– [Zubin] Yes, we have. Hey, crappy negative lady, this is a real thing, you know?

– [Rachel] Zubin.

– [Zubin] Yeah?

– [Rachel] Two hours?

– [Zubin] We actually covered some of this other stuff, emotions on kids.

– [Rachel] Dear lord.

– [Zubin] I think what we’ll do is we’ll skip migraines this time.

– [Rachel] Yeah, no, skip.

– [Zubin] We talked a little bit about anxiety, but what I want to talk about is therapy, because this is an action item.

– [Rachel] Okay, let’s end on that one. Let’s end on that one.

– [Zubin] You’re a therapist.

– [Rachel] I am, therapist.

– [Zubin] That’s right. “I’ll take the rapist for 400, Jack.” “The category is therapist.” Did you ever see… I’m not even going to quote this, just too much.

– [Rachel] I know what you’re gonna say.

– [Zubin] It’s “Arrested Development.”

– [Rachel] Yeah, I knew it.

– [Zubin] Yes, yes.

– [Rachel] That’s my favorite. It’s my favorite.

– [Zubin] It is, right?

– [Rachel] Is it too inappropriate?

– [Zubin] I won’t say it, but I’ll just say-

– [Rachel] It might be too inappropriate.

– [Zubin] It’s an analyst and a therapist. He wanted to combine them together.

– [Rachel] And he did on his business card.

– [Zubin] And he did.

– [Rachel] And that word is a good word.

– [Zubin] And it was amazing. That was Tobias, wasn’t it?

– [Rachel] Tobias.

– [Zubin] Tobias Funke, so good.

– [Rachel] Yeah, it’s such a good show.

– [Zubin] Therapy, I had a terrible experience in therapy a few years ago and I didn’t feel like my therapist helped me at all. It made me want to give up on therapy together. Should I quit and find someone else or just quit for good? Maybe therapy isn’t for me. How do you find a good therapist? How do you even know if therapy’s helping? Mike D.

– [Rachel] You know what I love about Mike D?

– [Zubin] He’s also a Beastie Boy?

– [Rachel] Yeah.

– [Zubin] Right?

– [Rachel] Yes!

– [Zubin] We did it. Tomax and Xamot for the win. Ho.

– [Rachel] I saw Mike D and I was like, this is a sign from God, because the Beastie Boys have now called in.

– [Zubin] It’s “Licensed to Ill.” You’re a New York girl.

– [Rachel] I am and you’re a Jersey guy.

– [Zubin] How can you not love the Beasties?

– [Rachel] How can you not love the Beastie Boys?

– [Zubin] Yeah, can not, yeah.

– [Rachel] Okay, the most important thing to say, and I’m going to ask you your opinion about this also.

– [Zubin] Oh, no.

– [Rachel] Even though you’re not a therapist.

– [Zubin] That’s right, anal rapist.

– [Rachel] Careful.

– [Zubin] I said it, see. It was Tobias. That was from “Arrested Development.”

– [Rachel] Yeah, that was. Okay, going to one therapist and having a bad experience, and then deciding that therapy is bad, or not for you, is, in my mind, the equivalent of going out to dinner and eating a bad meal and deciding that food is bad. That is not true. People have bad experiences all the time, and I don’t mean to be mean, but there’s a lot of bad therapists out there. There are also a lot of good therapists, who are just not the right fit for you. I am not the right fit for everyone. I’m a very distinct personality, and I am the right fit for some people, and I am not the right fit for other people, and that is okay.

– [Zubin] Well, it doesn’t help that you start every therapy session with, chant with me, ancient spirits of evil, transform this decaying body into Mumm-Ra the Everliving. Sorry.

– [Rachel] I do not-

– [Zubin] “ThunderCats.”

– [Rachel] Start any of my episodes or sessions that way.

– [Zubin] Ho, back to you. Yeah, you’re not a fit for everyone. You have to find that right therapist that’s the personality for you. Keep going.

– [Rachel] Well, just generally speaking, when you go shopping, do you try on a couple pairs of shoes before you buy a pair?

– [Zubin] No way, dude. I try on 25 and then I ask the guy. I was like, “So I have a little bit of a valgus deformation “of my foot. “What do you recommend?” And it’s like Foot Locker, and he’s like, “Bro, I don’t even know half the words you just said.”

– [Rachel] Try these high tops.

– [Zubin] Why are you not wearing socks?

– [Rachel] Try these Air Jordans.

– [Zubin] Air Jordans, nice, exactly. I’m like, if I can’t pump it up, it’s not a real shoe, man. It’s not a real shoe.

– [Rachel] Oh my God, that’s how I feel all day.

– [Zubin] Do you know what I rolled with when I was a kid? Talk about being bullied. I had the Pro Wings, which were the Payless Shoe Store’s Velcro strap shoe.

– [Rachel] I’m so jealous.

– [Zubin] And I was like, what? Sixth grade? And the kids are like, “You got those, Dogg? “Those cost $10.” I’m like, “Yeah, but they’re so comfortable.” And then it would just… It would just rip. Yeah, my poor mom. She didn’t know.

– [Rachel] Man, this just got dark.

– [Zubin] Yeah, it got dark. Anyways, back to… Speaking of dark, bad therapists.

– [Rachel] No, back to shoes.

– [Zubin] Oh, sorry.

– [Rachel] Back to shoes.

– [Zubin] You’re talking about different shoes you try. How many shoes do you try on?

– [Rachel] Sure, so you try on 72 pairs and you ask very important medical questions. Most of us go in and try on like, I don’t know, five or six pairs, then you get a pair that fits you, yeah? That’s just for your feet. If you’re trying to figure out shit with your brain, don’t you think it’s worthwhile to try on a couple of therapists to find the one that fits your brain the best? If you’re going to try on 25 pairs of shoes, give yourself permission to go out there and try on a couple of different therapists and see which one feels right to you. That is my humble recommendation for everybody. Everyone needs a therapist. I really believe that. I have a friend who said, “Gosh, all of these people spend so much time talking “about their physical health and how many miles they biked “on Strava and how many miles they rode and how many hours “they did yoga, “but imagine what the world would be like if all of us “were like, ‘Yeah, man, I worked on my shit in therapy today “‘for two hours,’ “and just how different the world would be if we talked “about our mental health and our emotional health, “as much as we talked about our physical health.”

– [Zubin] Yes, that’s why, honestly, that’s why I brag a lot about how much I meditate. It’s not bragging. It’s like, guys, I do this. I take this very seriously because self-improvement, self-knowledge, self-introspection is important in general, but it’s important to me and I wanna model it. I wanna virtue signal it. I’m like, guys, let me show you.

– [Rachel] Mindfulness and meditation are a very important part of someone’s wellbeing and health, and I will say therapy is a different animal.

– [Zubin] Yes, it is.

– [Rachel] And to this person’s question, how do you know if it’s even helping? Sometimes, I’m just going to say this, even though maybe it will turn some people away, it doesn’t always feel good and it’s not supposed to. It’s not supposed to. Eating vegetables when you’re a kid also isn’t delicious, but it’s really good for you and it helps your body grow. It helps you become really big and strong, and the same is true with therapy. If you actually wanna evolve, sometimes that requires looking at things that are painful about your past or about yourself and moving through it. Changing patterns sometimes is not the most fun, comfortable thing, but if you have a good therapist, it’s pretty awesome.

– [Zubin] Yes, I’m gonna triple down on that and say pushing yourself into some discomfort is almost a requisite for real growth in this way. If it’s all unicorn farts and whatever, it’s very unlikely, I think, that you’re gonna find… In a way, you’re almost going in a confirmation bias kind of thing, ’cause some people do. They seek out therapists that just validate them or-

– [Rachel] That’s not real therapy in my mind. A yes man? A yes man is very nice. I know a lot of people who see yes men therapists, including family members, and nothing changes.

– [Zubin] Nothing changes.

– [Rachel] They just get the yes.

– [Zubin] Yeah, “Oh, well, “your feelings are completely valid ‘and you shouldn’t do anything.”

– [Rachel] “Everyone in your family is crazy “except for you.”

– [Zubin] Except for you, that’s right, so we have seen that, even in… Yes, I have very close people that have had those experiences.

– [Rachel] That’s not good, it’s not.

– [Zubin] So it becomes difficult because you have to try to find that right person, but it’s not necessarily their right that they make you feel so good.

– [Rachel] That’s right. That’s right, no, and just to say, support is great. Having an advocate, very important, but if your therapist isn’t calling you out gently, kindly, supportively on things where you could use some help, then therapy, in my mind, might not be happening.

– [Zubin] Yeah, it’s more like a friend that’s telling you what you want to hear.

– [Rachel] And I know those friends and I love those friends and I call them, ’cause I need them to say nice things to me and to just say yes.

– [Zubin] Exactly.

– [Rachel] But that’s not therapy.

– [Zubin] That’s not therapy. That’s important. That’s something people don’t really dive into.

– [Rachel] So I really believe that everyone could benefit from having a therapist to support them. Insurance is broken, but most people have sufficient insurance coverage that they can get some sessions covered, and you’re allowed to poke around and find a therapist that you think fits your unique brain, just like you should find a shoe that fits your unique foot, even if it’s a pump up Air Jordan with Velcro and glitter.

– [Zubin] Which insurance does not cover.

– [Rachel] No, unfortunately.

– [Zubin] I tried.

– [Rachel] Z.

– [Zubin] We did a thing.

– [Rachel] This was rad.

– [Zubin] This was fully radical. I’ll spell that word out.

– [Rachel] So interesting.

– [Zubin] I’ll put it out to five digits like pi.

– [Rachel] Amazing.

– [Zubin] It’s all the pi I know.

– [Rachel] We should tell people how to send us more questions.

– [Zubin] Yes, how will they send us more questions? You can email me through my website, ZdoggMD.com, scroll to the bottom. There’s a contact form.

– [Rachel] Twitter is best for me.

– [Zubin] Twitter is good for you and put-

– [Rachel] I’m @DrZoffness on Twitter. Is that right? @DrZoffness? I think that’s right.

– [Zubin] Yes, that is correct, and what I would say is you put in… If you message me, put in #painpoints or Rachel Zoffness and I will look at it in a certain way and forward it to you, and our process is I take a look, I go, oh, interesting, I forward it to you. You then go, ah, and then we create a thing and we do a thing and we’re gonna do it regularly, because it’s a thing. Pain Points, I like that name actually, and if people don’t like it, they can deal with it, okay? ZZ Doc was taken by no one ever ’cause it’s dumb. Actually, it’s kind of funny.

– [Rachel] I like that too.

– [Zubin] ZZ Doc.

– [Rachel] Yeah.

– [Zubin] I feel like I should grow a beard and have a Sword of Omens that we’re gonna sign out with.

– [Rachel] Ho.

– [Zubin] That’s right. Let’s do it together. Guys, I love you. If you love Pain Points with Dr. Z and Dr. Z, share the show, become a supporter, go to ZDoggMD.com/supporters, and you can pay for all this, and I will even throw a couple bucks Rachel’s way by buying her a meal, mostly Raisin Bran, because I find it to be a high-fiber treat that is also very high in sugar, and thunder, thunder, thunder, ThunderCats, ho.

– [Rachel] Ho.

– [Zubin] And we’re out. We’re out. We’re out. We’re out. We’re out. We’re out. We’re out. We’re out.