Grit in Psychological Health and Illness

I've recently finished reading a book called Grit, by Angela Duckworth.  The author is a research psychologist who is part of the faculty at Harvard University.  She also has a background and interest in childhood education, which is very relevant to her other work.

It is a good overview of the research that has been done about the factors that lead to success and achievement in various domains of life, such as in a profession, in athletics, and in the performing arts.

The author's thesis, in a nutshell, is that "grit", which she defines as perseverance over a long period of time, the practice of being undeterred by failures or disappointments, and the maintenance of long-term purposeful goals, is a much stronger factor leading to success, compared to hereditary factors or "talent."

While this may seem like an obvious truth, it is important to realize that the educational system, and the culture as a whole, tends to value the idea of "talent" more strongly than the idea of "persistent hard work."   In one interesting study, an identical performance was judged more highly if the observers were told that the performer was "talented" compared to being told that the performer had "worked really hard."

How is this relevant to mental health?

Here are some of Duckworth's ideas, applied to mental health management:

1) if you are working on mental health, consider that it is necessary to work on this for years.  Duckworth's research shows that successful endeavours in almost all spheres of life require a commitment of at least 2 years' time.  During this time, it is necessary to have diligent, daily practice.  This is not unlike the routines needed by a musician or athlete.  This work needs to be guided by a long-term meaningful vision.  The work may at times be difficult or even painful, and the work may be interrupted by periodic failures.  The disappointing times must be accepted without allowing them to interrupt the work.  In fact, it is necessary to learn from the disappointments rather than be derailed by them.

2) Duckworth ponders the unresolved question of whether the daily disciplined work needed for success must be "enjoyable."  A lot of the work, in athletes for example, shows that the workouts needed for excellence are not, or cannot be, truly "enjoyable."  The required work must challenge the status quo of your body's physiology and reflexes, and this is never easy to do.   In this sense, a recipe for excellence is a tolerance for discomfort, which could be nurtured through practice.  But I think this view could be reframed:  the hard work needed may in the moment be uncomfortable, but provided there is an overarching sense of meaning and joy which guides the process, the periods of intense work would then fit into a paradigm of balanced health.    I also believe that a good therapist, teacher, or coach, should always strive to make hard work as enjoyable as possible.  Therapy itself may sometimes be quite joyful, and need not always be emotionally taxing.

3) In order to facilitate the years of work and discipline needed for growth and change, it is usually necessary to be part of a culture or community of change.  Athletes are usually part of a team, whose members motivate each other.  Musicians and academics hopefully are part of communities whose actions challenge and maintain growth and practice.   It can make a huge difference to have a dedicated teacher or coach who believes in you, who sees your potential, and who challenges you to work hard.   In mental health, I think a good therapist can have a "coach-like" or "teacher-like" role in this way.  I think a good therapist should strive to be inspiring, motivating, but also challenging.

4) As Duckworth shows, it is necessary to have a sense of purpose in order to be able to commit to years of hard work.  In depression, it is often the case that a sense of purpose is weakened or lost.  It is of the utmost importance in therapy to address the issue of meaning.  Without meaning, the hard work required for change could feel like a terribly draining, pointless chore.   But how can we recapture meaning which has been lost?  Maybe sometimes it is not so easy, but we can start by at least addressing it in conversation, and exploring possibilities.  Often, in depression, meaning can be rekindled through behavioural exploration, in conjunction with relief of symptoms.   In other cases, meaning can be recaptured even when other symptoms are at their worst.

5) One of the connotations of this type of work is that short-term models of mental health care are unlikely to lead to mental health "excellence," unless they serve merely as preliminary introductions to new ways of being.    Just like in a successful classroom, sports team, or company, the atmosphere of change must allow for a sustained, long-term commitment.    But it is an important critique of some longer-term therapy, that it can become too passive, just like the situation in which a teacher or coach becomes resigned to a class or a team which is not thriving.  A good therapist, just like a good teacher or coach, must always strive for growth and change, while also helping the process to be as joyful and meaningful as possible.

Audio and Video recordings of Positive Affirmations

In my last post, I was discussing a technique of practicing exposure to recordings of upsetting thoughts.

This same idea can be applied to positive thoughts too!

I encourage you to collect ideas, quotations, and encouragements.  Write them down, and then make an audio or video recording, using your own voice.

Choose a time when you are feeling calm and comfortable.  Make your recording a type of message to yourself, a message of support and encouragement.

Your encouragements could be quotations from a cognitive therapy exercise, in which you were reasoning or problem solving in response to negative thoughts.  Or they could be passages from a gratitude journal, in which you express thanks for any positives in your life.  Or they could be things you might say to someone else who has struggled or suffered in the same way that you did.  Or they could simply be simple, kind encouragements directed towards yourself.  For example, you could record something like "You are a beautiful person, full of kindness, love, and potential.  The world needs you. Take care of yourself...whatever hard times you are having now will pass..."   If you make a video, smile at yourself, and gaze at yourself with loving, compassionate eyes.

After you make your recording, it would be something to listen to or watch frequently.

Unlike the exposure therapy exercise, the goal here would not be to face a fear and strengthen yourself against it, but rather the goal would be to practice absorbing and accepting the positive messages.  If you listen to a piece of music frequently, the tune will eventually "play itself" in your mind, and your memory for this music will become more and more effortless.  Similarly, these positive recorded messages could become more naturally integrated into your memory.

I think that hearing your own voice, and seeing your own image, are more powerful influences on your mind and your thinking, compared to only working with your ideas using written text.  Hearing yourself speak is much more like experiencing your own thoughts, compared to reading your own written words.

Exposure Therapy for Worries, Intrusive Thoughts, Ruminations, and Obsessions

Worries, ruminations, intrusive thoughts, and obsessional thoughts can be a terrible source of suffering.  If they are mild or infrequent, they can be part of a healthy, balanced life.  But when they are occurring frequently, they interfere with all of our activities.  They make it hard to enjoy anything.  A beautiful walk in the forest is interrupted by upsetting thoughts about daily stresses, or about painful events that happened long ago.  Attempts to work or study are interrupted constantly, preventing you from getting things done, and certainly preventing you from enjoying what you are doing.  If the intrusive thoughts have to do with past traumatic events, it is as if these terrible events are happening to you all over again.

In this post, I am exploring a challenging approach to this.  But I know that in many cases upsetting thoughts cause extreme pain and suffering, and therefore any therapeutic approach must be considered with very great care.  The approach I am proposing may not be right for you, unless you feel very well-prepared for work that could be difficult.   With any therapeutic approach, you must feel entirely in control of the therapeutic process.  You must never be pushed into any sort of therapy, even by a well-meaning therapist whom you trust entirely.  Sometimes the framework of therapy implies that you should be doing certain types of work.  Just coming to a therapy appointment can implicitly push you into engaging with certain therapeutic tasks, such as sharing a painful story about your past.  

But I believe it is of the greatest importance to be guided entirely by your own will, with any therapeutic task.   

Upsetting thoughts are problems in which an event is happening outside of your own will.  Past traumatic events also have happened against your will.  So it would be wrong to engage in a therapeutic effort, unless you are very clearly in agreement with it, and you are engaging in each step with the full force of your will and consent.

I am also aware that many therapeutic ideas can seem too focused on some particular "technique."  Sometimes we can focus too much on "technique" in such a way that we are distracted from the larger picture.  In the big picture, I believe that healing forces include gentle self-care, empathy, healthy lifestyle, and loving relationships.  So, regardless of whatever "techniques" you try, be careful to remember that the "big picture" factors are the most important of all.

But let's get started on looking at some "techniques," with these limitations in mind:

What strategies or techniques can help to manage anxious thoughts, worries, or ruminations?


The Problem with Relaxation Techniques

Most people, including therapists, focus on techniques to help calm the mind.  These could include relaxation or meditation techniques.  Most of us would also encourage healthy distraction techniques, such as trying to read a book, listen to music, "breathe," go for a walk, talk to a friend, have a bath, etc.  Many medication treatments also focus on relaxation.  Benzodiazepines, including lorazepam (Ativan), clonazepam (Clonopin), alprazolam (Xanax), or diazepam (Valium), often literally calm the mind, slow down racing thoughts, and reduce the distress caused by rumination or worry.

But the problem with these approaches is that they are primarily avoidance-based, rather than strength-based.

Analogously, if you are very fearful about swimming, it will absolutely relieve your anxiety if you distract yourself, meditate, read a book, or take a sedative, whenever you are close to a swimming pool--but, of course, these techniques will not help you to cure your anxiety!  The only cure must involve deliberately approaching the water, and gradually facing your fear!

In many cases, relaxation therapy (especially if it is the only approach used) can make underlying anxiety worse, because it consolidates the notion that the anxiety is intolerable and must be avoided.

Exposure-Based Techniques

Over the years, I have become more and more a fan of behavioural therapy ideas, for approaching a wide variety of psychological symptoms.  I believe that this approach is strength-based, and is similar to having a physical fitness regime, or a structured program of learning a new skill (such as speaking a new language, playing a new sport, enjoying a new hobby, or playing a new musical instrument).

To treat a phobia about swimming, it is easy to prescribe a behavioural therapy program.  The first step might be to just watch people swim, while you sit in the bleachers.  The next step could be sitting at the side of the pool, with your feet in the water.  Eventually you might walk in the shallow end of the pool.  This could build up to putting your head under the water, learning to float, etc.  Eventually, with practice, you could be swimming laps in the deep end (maybe with the help of a swim teacher).

But how could we devise a plan to treat anxious thoughts or ruminations, using this type of approach?

An idea I have been working with is to encourage patients to make a detailed record of anxious thoughts or ruminations.  Try to "catch" the thoughts verbatim -- as though you are taking dictation, or using quotation marks.  Then make an audio or video recording, of yourself reading these thoughts aloud, in a way which mimics as closely as possible the way in which the thoughts occur in your mind.    The recording then becomes something to practice listening to...the task is to sit calmly with your thoughts.  If anxiety comes as you listen, let it come.  Consider it a type of "workout" to face a difficult task.

As with other types of workouts, it is important to plan the duration and intensity so that it is challenging but not overwhelming.  It can't be too easy -- otherwise there would be no training or strengthening effect.  But it can't be too hard -- otherwise you could injure yourself, or just have an unpleasant experience that would discourage you from working out again.

With exposure to recordings of anxiety thoughts, you can adjust the intensity in a number of ways (this is analogous to adjusting the weights in the gym).  Here are three ways to adjust the intensity or difficulty:
1) just turn the volume of the recording down.
2) listen to the recording for very short periods of time, and gradually increase the duration as tolerated.
3) listen to recordings of thoughts which are less upsetting.  As you feel able, you can introduce more difficult or challenging thoughts.  
   

There are various phenomena that can happen which reduce the effectiveness of this technique.  The mind has strong reflexes to manage anxiety using avoidance.  When dealing with worries or intrusive thoughts, it is very common to want to respond to these thoughts by trying to reason with them, reassure yourself, problem-solve, or distract yourself in various ways.  With this technique, it is important to simply let the thoughts come, let the ensuing anxiety happen, without trying trying to reassure, problem-solve, or distract.

I am not saying that problem-solving is unhealthy!  Of course, problem-solving and reassurance are very important!  But not if they occur during this type of exercise!  Analogously, if you are lifting weights in the gym, you could roll the weight upwards using a ramp, instead of lifting it directly!  This would be using clever problem-solving to bring the weight to a higher point!  But you would not get stronger if you used the ramp!  Or you could use a flotation device in the pool...this would be a good solution to help you float safely.  But it would not help you to swim better, or to master your anxiety of deep water!

Another type of technique used commonly for managing worrying and rumination is "thought stopping."  There has been some research supporting it.  This would appear to be an avoidant technique.  But according to one analysis, the reason that thought stopping can sometimes appear to work is because the exercise often first calls for people to deliberately induce anxious thoughts!  Only after a period of exposure to the anxious thoughts do people then use a thought-stopping technique.  At this point, often the thoughts which are "stopped" are not the anxious thoughts themselves, but rather the compulsive self-reassurances or problem-solving attempts.  Therefore the thought-stopping is actually favouring a better anxiety exposure exercise!

Summary of the Technique

1) make a detailed list of anxious thoughts, to replicate as closely as possible how they occur in your mind
2) make a recording, in which you read these thoughts out loud
3) listen to the recording, as a type of psychological "workout"
4) adjust the volume, duration, and content of the recordings, so that it is moderately difficult for you, but not overwhelming.  Aim for an experience of "mastery" just as you would when you are lifting weights successfully at the gym, or when you are doing some other type of exercise
5) While you are listening, you could attempt to do other tasks that you normally would like to do, such as studying.  But work hard not to engage in "avoidance" behaviours such as distraction, reassurance, or even relaxation techniques
6) You could aim for about 20 minutes at a time...but you might need to start with much shorter durations, such as a few seconds, if you are very sensitive.  Once again, it is like starting to do a new exercise such as running...you may need to begin with running just a few steps, and then building up to longer distances as you get stronger.
7) After each exercise, you could then do some relaxation or other pleasant activities...just like soaking in the hot tub after a workout at the pool or gym...
8) Pay attention to how you feel in the next few days.  Just like workouts at the gym, you might feel "sore" in some ways.  Sometimes you might have more upsetting thoughts or nightmares, and feel worse.  If this is the case, you may need to make the next "workout" easier.
9) You may need to have a guide (such as a trusted therapist) to help you with this.  The role of the therapist, with respect to this technique, would be like a "personal trainer" at the gym--the therapist would be there to support you, encourage you, and help you with any problems along the way.
10) Sometimes a particular technique, such as this one,  may not be right for you.  If this is the case for you, remind yourself that it is not a sign of "failure."  It is just a sign that a different strategy is needed for now.  You might come back to a technique like this at a later time, or you may find other techniques that suit you better.


Is there still a role for Relaxation Techniques? 

To carry the fitness analogy further, I think most of us like to relax during part of our physical workouts.  Before or after our exercise, we might like to stretch, warm up, cool down, or relax in a hot-tub or sauna.  This could add to the enjoyment of the workout, and possibly even reduce the chance of injuries.

With an exposure-based anxiety management technique, perhaps some relaxation-oriented ideas could be used before or afterwards, in the same way.  It could help make your work a little bit more enjoyable, part of a pleasant routine.  It would just be important that your relaxation technique does not cause you to indulge in some kind of compulsive pattern that could contradict the work you were doing.

How other techniques already use this idea

In mindfulness-style meditation, the strategy is not to "empty your mind" or to prevent anxious thoughts.  The goal in mindfulness is acceptance and practicing attention without excessive reaction to sensations, feelings, or thoughts.   Worries or intrusive thoughts are viewed as clouds drifting through the sky of your consciousness, rather than attackers which need to be confronted.  Therefore, a person practicing mindfulness is also practicing being with the upsetting thoughts, rather than avoiding them.

In EMDR, various upsetting thoughts or memories can be contemplated while doing a physical activity.  In this way, arguably, the eye movements have a catalytic role to allow exposure practice to occur in a framework which feels therapeutic and well-boundaried.  A weakness in this technique, and possibly a reason that EMDR may work better with some therapists or clients than others, is that the eye movement activity could in some cases be an excessive distraction, and therefore dilute the effectiveness of the other therapeutic work.  But I think that provided this potential problem could be addressed, EMDR techniques could help a client and therapist adjust the intensity of a therapeutic session, analogous to adjusting the difficulty of a physical workout.

In conventional CBT, the initial phase of paying attention to upsetting thoughts, and recording them, is already a type of "exposure."  The act of writing something down can often require a strong act of will, and carry powerful symbolic value.  But a problem with cognitive therapy can sometimes be that the thought records become distractions, foster rumination, or lead to excessive debate or intellectual argument about thoughts.  

In psychodynamic styles of therapy, the experience of freely discussing painful thoughts and memories also involves exposure to the strong emotions associated with them.  Sometimes, in this style, the therapist's quiet presence is not directly "reassuring."  Rather, the therapist has a quiet role of facilitating exploration without a need for direct reassurance or problem-solving.  But a problem with psychodynamic styles has to do with its passivity--there is a lot of focus on exploration and "interpretation" but often not enough focus on strength and practical, immediate, active mastery of symptoms.   The preoccupation, in psychodynamic therapies, of searching for remote causation of symptoms, can distract clients or patients from working on strategies to master their anxiety in the present moment.  

Limitations

For many people, intrusive thoughts are occurring so frequently and intensely that it is hard to recommend deliberate exposure to even more upsetting thoughts.  It would be like recommending a demanding physical workout to someone who is exhausted or injured from a grueling daily routine of hard labour.    In these situations, it may be important to look at other techniques, including more of a focus on relaxation, or on medication, to help reach a state of calm restfulness, before beginning an exposure-based strategy.

If there is a history of psychosis or mania, then there would have to be a lot of caution about using this type of technique.  But I would not rule it out entirely...there is more and more evidence about CBT-style ideas being useful in managing psychosis.

If negative thoughts are part of a volatile pattern leading to dangerous behaviours, including suicide attempts, self-injury, destructive bouts of anger, or severe dissociation, then very great care would have to be taken to make sure that this type of technique was used in an especially slow, cautious manner if at all.  There might have to be some preparatory steps to make sure that the situation was safe and stable enough to proceed.  This is again similar to recommending a physical exercise routine to someone:  it is important to make sure that a person does not have joint problems, heart disease, etc. which could make the exercise dangerous.

In some types of depression, a person can feel self-destructive.  With this technique, excessive exposure to the content of upsetting thoughts could be self-injurious.  Self-destructive behaviour would need to be addressed first, in order to allow a technique such as this one to be safe and helpful.  
One of the most important things, with any type of therapy, but especially with a process such as this, is to frequently emphasize that it is completely up to the client or patient to engage with the technique or not.  The therapist must never push this.  The client must feel completely free to stop the technique at any time, without any concern that the therapist would somehow be disappointed or disapproving.


The Role of Medication

A goal of medications is usually to reduce anxiety directly.  But I think it is important to think of effective medication as a "catalyst" rather than a direct "cure."   Medication may reduce the severity of the underlying problem, so that other types of therapeutic work could take place more effectively. The effect of medication could be analogous to reducing the weights in the gym, or to using a flotation device to help you practice kicking in the swimming pool.    Without medication, sometimes the symptoms could be so severe that it is much more difficult or painful to do the therapeutic work.  It would be like going to a gym where the only barbells available had 200 pounds or more on them!

Some medication can also theoretically improve sleep or restfulness, and therefore allow you to do better and more enjoyable therapeutic work the next day, when you will feel more rested.  In other cases, medication could help with energy, allowing you to become more actively involved in all therapeutic tasks.  

Another dynamic in PTSD can be that uncomfortable experience is too quickly assimilated--perhaps via the amygdala--into a strong, aversive "emotional memory."  Past trauma, in combination with inherited factors, can make this type of neural pathway hypersensitive.  Arguably, some medications, including beta-blockers and other adrenergic antagonists,  could reduce the intensity of this reflex.   This would be analogous to a person with arthritis using an anti-inflammatory medication before doing physical exercise--the medication would allow the exercise to occur more comfortably, and with a lower chance of injury.     But I have to admit that it can be hard to find medications that are consistently helpful for this type of problem...I do think it is good to have an open mind about trying different approaches.


Conclusion

Upsetting thoughts can be a difficult problem, but I encourage patient, gentle persistence in a search for relief.  Remember the big picture, of patient, gentle self-care, healthy lifestyle, and nurturing loving relationships.

I do invite you to consider the possibility of finding ways to approach upsetting thoughts in a way which seems paradoxical--by finding a way to face them directly, and to practice having the thoughts rather than practicing ways to get rid of them.  This practice is not meant to be masochistic, but rather is meant to build a strength inside of you, so that the bully-like emotional effect of upsetting thoughts is gradually weakened as your strength improves.

References

There are not enough research studies done regarding approaches to rumination, primary obsessions, and other intrusive thoughts...but a similar exposure-based idea is described by  Salkovskis & Westbrook (1989).  I will look for other articles to expand my list of references later.

Salkovskis, P. M., & Westbrook, D. (1989). Behaviour therapy and obsessional ruminations: can failure be turned into success?. Behaviour research and therapy, 27(2), 149-160.

Garden metaphor

This is an update of a post I originally wrote in 2008.

The brain, or the mind, or your life, is like a garden.

It has grown for many years, and there are aspects to the structure that are, or become, permanent (e.g. the size and shape of the garden).

Some structures in the garden may be dominant (e.g. a tree that monopolizes sunlight, water, space, or nutrients).

Some structures may be permanent (a tree), others transient (some small flowering plants).

There may be weeds in the garden. Or maybe they are only "weeds" because someone has said they are weeds, just because they are considered weeds by other gardeners. Maybe the beauty and importance of many so-called weeds are overlooked.

There may be parts of the garden that are profoundly important, extremely beautiful, and extremely complex, yet are not noticed because we haven't looked in the right way (e.g. tiny flowers; micro-organisms; ladybugs; close-up views of the structure of the leaves, etc.).

Old or dying plants may be integral parts of the normal life cycle of the garden, as things of beauty in themselves, and as components that help new life to grow.

There may be diseases in the garden that do harm in different ways (above the soil or below).

There may have been terrible events long ago that have done severe harm (a fire; an oil spill; a vandal; a careless former gardener; bad droughts or storms; a lighting strike).

The garden requires a healthy environment to grow, both above and below the soil. Sunlight, water, nutrients, soil conditioning.

The structure of the garden can get tangled up and confused if it isn't tended to regularly. It can get messy. The tangles may prevent certain beautiful plants from being cared for or thriving. The tangles can occur above the ground, or down underneath at the root level.

The structure of the garden can be stunted if it is tended excessively -- the overzealous pruner who cuts too many branches away, instead of letting the natural shapes and stems grow spontaneously.

In healing a troubled garden, sometimes simple, broad measures can make a huge difference (e.g. adding nutrients to the soil; introducing a new type of soil; keeping up this supplementation for months or years).

Other times, or perhaps in conjunction, work may need to be done to prune or guide the garden differently, above and below the ground. Some of this work can happen in a day, other aspects of this work could take years.

Maybe a major change is needed. A huge plant that is taking up all the space, water, and light, may need to be removed, so that other plants have a chance to grow.

Sometimes things that supposedly help need to be cut back -- maybe the garden is being over-watered, or is getting too much sun. Many of the plants may require moderation in order to thrive. There can be too much of a good thing.

New species may need to be introduced, to balance the health and esthetics of the garden. Synergistic benefits can happen with the right combination of species (two different species may help each other grow if they are adjacent to one another).

The effects of past trauma in the garden may gradually heal with care and attention. Some of the scars of the trauma may remain forever. Even if these scars remain, the other plants of the garden, and the gardener, can support the injured plant, help it be a vital, important, and beautiful part of the garden community.

While caring for the garden may be hard work, the process is intrinsically a joy. The results of the gardening are part of the health, but so is the process of the gardening activity itself.

In caring for your mind, you are taking on a role of gardener.  It is possible to "tend the soil" in many ways.  Part of this requires physical labour to improve the texture and drainage.  Sometimes the soil may be depleted or damaged in some way, and a fertilizer may be needed, at least for a little while.  This could be similar to using medication.  But also there are many other ways to care for the "soil," such as by having a healthy diet.  Psychotherapy is analogous to hiring a gardener to help and advise you, and maybe to work with you, kneeling in the soil, or pruning the branches.  Sometimes major structural changes may be needed, to plant the garden in a completely different way...this is akin to making a substantial change in the organization of your life, your goals, and your relationships.  And the best gardens are attuned to the larger ecosystem around it, including other gardens in the neighbourhood.  This is analogous to the need to healthily engage in your community, and in relationships with others.    Part of the life of a garden, and of a gardener, also requires simply sitting down and enjoying its beauty.

There may be hard work to do, but there must also be a lot of time spent simply savouring your efforts, and enjoying the view.  I hope that a good therapist might do this with you as well.  Make sure there is a bench in your garden, in a shady spot, in order to rest and enjoy.  In your life, there may be a lot of work to do, but make sure to spend time, every day, sitting down and enjoying what you have been working on.

The Virtue of Admitting Weaknesses

I think it is a virtue to admit areas of weakness.  In our modern, competitive world, we are encouraged never to admit our shortcomings.  On a résumé or CV, the standard practice is to provide a list of our accomplishments, awards, and strengths, but never to discuss weaknesses!   In current events today, we can find many examples of public figures who not only would never admit any sort of weakness, but who boast about themselves almost constantly!   Admissions of weakness could seem like manifestations of low self-esteem, low confidence, or proof of incompetence.  

I think it is a strength to be able to admit weaknesses!  It is a protection against poor decision-making, and a protection against cognitive biases, to always contemplate weaknesses or mistakes in your planning.  For example, Kahneman described a technique called a "pre-mortem" which calls for us to anticipate or imagine that our plans had failed badly, and then to imagine the sequence of events that could have led to the failure.   Too often, groups are so excited about new plans that they are blinded by "groupthink" and do not consider adverse consequences.  While this often happens in business planning, it frequently occurs in our personal lives as well.  

In medical training, it can be important to show confidence.  But imagine how dangerous it is for patient care when a trainee is reluctant to admit a weakness in performing a medical procedure!  In this case, it is a sign of strong professionalism and leadership to admit that you don’t know.  Ironically, it can require great confidence and self-esteem to be able to convey these weaknesses honestly.  

 In the spirit of admitting weaknesses, I would like to list a few things that I don't think I'm very good at, in my professional life: 

1) teaching meditation.  I know that meditation skills can be important and powerful.  I encourage almost all my patients to learn about meditation, and to consider investing a lot of time practicing meditation skills.  I think I am good at philosophizing about meditation...but not really good at meditation itself! Mind you, I do think that my philosophizing has a meditative quality--at least it does for me! 

I am willing and eager to learn more about meditation, but I also know that a good meditation teacher or group would be more effective and helpful for my patients to learn meditation skills.  I feel the same way about some other related activities such as yoga. 

2) being a very organized, methodical teacher (e.g. for CBT exercises).  I love intellectual dialogue, and I enjoy trying to give encouraging, creative feedback...but I know that sometimes a good teacher needs to be very organized, consistent, strict, and focused on a task...My style tends to more informal, with variations of focus from week to week, according to my patients’ wishes.     Also, I tend to question things a lot, including the process of things, so I think I would find a highly regimented style to be too restricted.  Some patients who desire a more strictly regimented approach might get frustrated with me.  At other times, maybe I don’t use time as efficiently as I could.  

I am willing to learn more about becoming a better and more organized teacher--but I also recognize that I have limitations with those skills, and that there are others who could do a better job than I could.  

3) "Networking" with community resources.  I have a tendency to have a bit of a "monastic" style.  While I encourage patients to inform themselves about community resources, and to make use of them, I tend to prefer spending most of the time working one-on-one with my patients, instead of spending time developing relationships or engaging professional peers in other parts of the community.  For similar reasons, I prefer to do a lot of my continuing education activities on my own, through reading and writing, rather than signing up for conferences.  

I realize that we all need a balance between "alone time" and "group time" in our lives.  This applies to professional life as well--different professionals may like or need different amounts of interaction with professional peers.   I think it is unhealthy for anyone to be too extreme in this balance, but on the other hand I do think it is important and good to honour your own personal style.  

The practice of psychiatry nowadays tends to favour more "community networking" and less of a "monastic" style.  I see that this can be valuable, because it could lead to more of an experience of a collaborative therapeutic community.    For me, I guess my lack of inclination to network this way is a weakness...but I hope some might find it a welcome strength that I value the one-on-one experience as highly as I do.

4) not empathizing enough.  Sometimes I focus too much on intellectual dialog, on problem-solving attempts, on being calmly attentive, etc. – but then I don’t say an empathic comment that needed to be said.  Here, I need to be more diligent to work on this, but also maybe to admit that this happens more often than I care to admit.  

I have a variety of other weaknesses.   I encourage a practice of being honest about our weaknesses, not in a resigned or self-deprecating way, but in a way which helps us acknowledge our humanity and our fallibility.  

Ironically, I am concerned that I might sound boastful -- I am boasting that I can talk about my weaknesses!  Maybe my own boastfulness is another weakness, to be worked on.

  
Also, in conjunction with admitting weakness, I think it is good to acknowledge that some of our strengths actually depend on the weaknesses!  Maybe my weakness regarding networking comes along with a strength for valuing one-on-one therapeutic relationships...perhaps some of your weaknesses which you struggle with are part of a larger picture of having strengths which could allow you greater meaning and purpose in life.

With the admission of weaknesses, I think it is also good to be open-minded about working on them.  Not necessarily with a goal to become a different person--it is important to "be yourself"--but with a goal of spending a little bit of time and attention on our weaknesses in a constructive way.  For me, this means that I need to spend a little bit more time learning about meditation.  I need to consciously say more empathic remarks.   I need to maybe sign up for a few more conferences.  And I need to push myself a little bit to attend more meetings with colleagues in the community.   But I can’t let these goals interfere with the aspects of my professional life that I already enjoy and feel comfortable with.