Life is Combat, 3


With all the practice in the world, when the rubber meets the road and life calls on us to perform, we’ll still experience stress. How do we manage that stress in the moment?

Robert offers us two strategies: Tactical Breathing and Cognitive Reframing.

Tactical Breathing

We have direct access to breath and muscle tension. This gives us two “knobs” we can use to calm ourselves in the midst of stress or to increase our arousal level when needed. As we slow our breathing and seek out and relax muscle tension, our heartbeat and blood pressure will follow suit, allowing us to become more calm. Breathing more  forcefully and tensing muscles can raise our alertness level and prepare us for strong, rapid action when needed. Thus, we can tune our physiology to the demand facing us in each moment.

One approach to breath control is “square breathing” with each side of the square being four seconds long, or a slow count of four: 1) breathe in for four seconds, 2) hold for four seconds, 3) breathe out for four seconds, 4) hold for four seconds.

Other breath control approaches have also demonstrated the ability to induce calm and help control stress responses, suggesting that the important thing is not so much which specific technique is used so much as intentionally slowing and deepening the breath in stressful moments.

I like visualizing my breath as the hand of a clock. When my lungs are full, the hand is at 12. When my lungs are empty, the hand is at 6. As I inhale, the hand moves up from 6 to 12. As I exhale, the hand moves down from 12 to 6. By speeding up or slowing down the clock hand, I can fine tune the speed of my breath.

Cognitive Reframing

There are a couple of ideas behind cognitive reframing. The first consists of displacing negative thoughts of defeat and failure with positive self-talk.

Positive Self-Talk

Rather than, “I can’t do this,” or “I don’t know what to do,” we can call up encouraging thoughts like

  • This is what I’ve been training for
  • Relax and focus
  • Slow is smooth, smooth is fast

Design some encouraging thoughts you can call on in a crisis and practice them ahead of time. During visualization is an ideal time to practice deploying these and will make it more likely that they’ll come to mind when you’re actually facing stress.

One Thing At A Time

Another aspect of cognitive reframing is focusing exclusively on the next step. Our negative self-talk wants to tell us how big the mountain that’s about to fall on us is, how completely out of our depth we are, how completely we’re about to fail and disgrace ourselves.

Contemplating the big picture in the midst of stress is not helpful. Focus instead on the next step you need to take. You only have to do one thing at a time. Give all your attention to the one next thing. How do you eat an elephant? One bite at a time. Instead of thinking about the elephant, focus on chewing this bite.

Tactical breathing and a one-thing-at-a-time focus will enable you to navigate real-time stress to a satisfying outcome.


Black Box Thinking

After an airliner crash, the data recorders from the cockpit are retrieved and studied to understand what went wrong and how the system might be changed to make that error less likely in the future. Apply the same discipline to your failures.

In the aftermath of a failure, we have a choice. We can seek to avert blame and avoid responsibility, in which case we learn nothing. The other option is to examine what happened and look for lessons. We don’t learn from our good performances. Unless we take our failures as opportunities to learn, we’ll impair our ability to improve at all.

Robert writes, “Reconceptualise your relationship with failure so that it no longer represents an existential threat, but acts as a guide for your ‘practice’ phase.”

Even when a performance goes well, consider what might be improved. We are often encouraged to play to our strengths, and this is helpful advice when a competent performance is required. However, playing to our strengths doesn’t help us grow. Only working on our weaknesses will do that.

Self Compassion

The purpose of black box thinking is to learn what we can to enhance future performance. That goal is not aided by punishing or blaming ourselves. As we examine past performances for clues to improvement, we can also be gentle with ourselves, and this will also enhance our learning.

Just like stress shuts down our rational thinking, self-blame and guilt shut down our ability to learn. We need to treat ourselves with gentle compassion to allow ourselves to absorb the lessons we want to learn.


  • Stressful situations are inevitable. If we don’t train for them, they will find us unprepared.
  • Perceived demand > perceived resources => threat mindset
  • Perceived demand < perceived resources => challenge mindset
  • Mental toughness = 100% commitment + challenge mindset
    • Where is your commitment? 100% of it is somewhere.
  • Practice
    • Immersion — regular, periodic practice
    • Deliberate practice
      • specific, measurable, attainable session goal
      • maximal focus
      • immediate feedback
      • push your envelope
    • Visualization
      • physical – body position, arm and leg movements
      • environment – what do you see, hear, smell?
      • timing – slow to fast
      • learning – content should change with skill development
      • emotion – include stress
      • perspective – see what’s going on through your eyes, not out-of-body
  • Perform
    • Tactical Breathing
    • Cognitive Reframing
      • Positive self-talk
      • One thing at a time
  • Process
    • Black box thinking
    • Self compassion

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Posted by on 2017/10/10 in Uncategorized


Life is Combat, 2

In Life is Combat 1, I reviewed a series blog post by emergency doctor Robert Lloyd recounting his experience in dealing with trauma injuries in a township in South Africa and how his experience taught him about mental toughness, or resilience. Life is Combat, 1 and this post explore how Robert’s lessons about mental toughness in the face of severe injuries might be applied to the garden variety stress most of us deal with every day.

Robert divided his strategies into three “phases”: practice, performance, and process. The practice phase consists of pre-event preparation, or training. Performance is what happens in the stressful situation itself. Process is how we think about what happened afterwards. How we process past events helps determine how we will face future events.


During the practice phase, the goal should be to increase confidence in one’s skill set to increase the likelihood of a challenge appraisal (rather than a threat appraisal) when confronted with a stressful situation. During practice, it’s more important to focus on specific skills than to increase one’s knowledge. In the practice phase, we work on skill development through immersion, deliberate practice, and visualization.


Immersion is Robert’s word for setting aside time for regular practice sessions. What is to be done during these practice sessions is an open question. Some of the time may be devoted to finding new resources to help one develop the desired skills. It may be devoted to staying current on recent developments in, for example, what professionals are thinking in the stress management field, etc.

The important point to be made here is that it is necessary to set aside this time and be faithful to it. It’s the commitment to making and keeping this appointment with oneself that provides the space for growth in one’s ability to face and deal with unexpected but inevitable stressors.

Deliberate Practice

Deliberate practice consists of endlessly and relentlessly repeating the following loop:

  1. Where am I weak where I want to be strong?
  2. Drill that skill (or skill component) until the desired strength is developed.
  3. Go to step 1.

The following principles should guide one’s deliberate practice:

  • Set yourself a specific, measurable goal for the session. At the end of the session, you should be able to unambiguously answer the question, “Did I meet my goal?” Vague goals like “Improve” or “Succeed” are not very helpful. More helpful goals might be “Repeat the drill X times,” or “Get to the point that I can play the song I’m working on three times without mistakes,” or “Meditate for X minutes.” When you start working on a particular skill, you may not hit your goal for the first few sessions. However, if you go too long without a win, the practice will become frustrating and unsustainable. So you must also make your session goals realistic.
  • During a practice session, maximize your focus. Time your session so that the possibility of interruptions will be minimized.
  • Figure out how to give yourself immediate feedback on how well you’re doing. If what you’re practicing is something that allows you to see your success or failure as you’re practicing (writing or playing music or meditation), all you have to do is watch. If you’re practicing a skill where success or failure are not evident in the moment, you’ll need to devise some way of giving yourself feedback. If expert examples are available online in the form of video resources, you can compare your performance to what you see in the video.
  • Push yourself to edge of what you are capable of. The only way to enlarge your envelope is by pushing the edges.

Robert writes, “Human nature dictates that we gravitate towards training skills that we are already proficient at, and neglect areas outside our comfort zone. Why? It’s much more satisfying to feel like you are ‘nailing’ something. DO NOT be enticed into that trap – the significant gains exist where there is most discomfort and least enjoyment.” The greatest satisfaction comes from seeing yourself get stronger over time in areas of previous weakness.

Periodically, we have to repeat practice of areas we may have worked on in the past to avoid skill fade, the gradual loss of skills over time if they are neglected. Here is more detailed information about deliberate practice.


This is the process of generating and watching a “video” in your mind’s eye of you performing the target skill. The video should be from the perspective you see as you perform the skill (i.e., you aren’t watching from outside your body, but through your imagined eyes as your imagined hands and legs execute the target movements).

The more vivid and context-rich you can make the internal video, the more effective this process will be. Elements of this vividness include:

  • Physical: How is your body positioned? What are you wearing? What are your arms and legs doing?
  • Environment: What do you see around you? What do you smell? What are you hearing?
  • Timing: Ideally, your mental video should run as fast as the actions do in real life. An advantage of visualization is that you can slow down the video to emphasize specific points in the sequence as needed. You can also make the practice more demanding by running the video on higher speed than real time.
  • Learning: The content of your video should evolve as you learn and improve.
  • Emotion: One goal of the exercise is to develop skill that will stand up to stress. So one’s simulation should include feeling stressed but in the challenge (rather than threat) mindset.
  • Perspective: See the action from your own perspective, through your own eyes, not from an “out of body” location.

Vary your visualization with potential glitches that might crop up. What if she says thus-and-so? What if that happens? And so forth.

In the next post, we’ll talk about performance and process.

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Posted by on 2017/10/08 in Uncategorized


Life is Combat, 1

We all experience stress from time to time. Even for the most sedentary, routinized homebodies among us, life drops unexpected disruptions on us now and again. Unless we prepare for stressful events when life is stable and easy, such adversities will find us unprepared and vulnerable to break-downs and dysfunction.

In his multi-part series on mental resilience, Robert Lloyd describes the possible result:

  • “Tachychardia — severe palpitations
  • Ringing in my ears (auditory exclusion)
  • Negative, persecutory thoughts
  • Decision paralysis, inability to prioritise tasks
  • Loss of fine/complex motor skills (I was visibly shaking)”

“We don’t rise to the occasion, we fall to our level of training.” — Dave Grossman

Of course, stress responses may be more or less severe, depending on the perceived discrepancy between the demands of the situation and one’s internal resources for responding to it. Robert was describing his experience of working in a South African hospital in a township where a night’s shift might bring in over 30 injuries from serious community violence. Robert writes:

“Throughout that first set of weekend nights, I was overwhelmed by the environment. I was completely unprepared for the onslaught of young major trauma patients – it was unimaginable. Having never been exposed to anything even remotely comparable, an intense physiological and emotional reaction ensued. This was devastating to my performance…. In that first weekend in Khayelitsha, my mind and body let me down to such an extent that I was a useless member of the team, and a useless doctor to my patients.”

Robert might have given up, packed his bags, and headed home. Instead, he thought carefully about his situation and devised a plan to develop the mental and emotional resources he needed to cope and navigate the situation effectively.

First, let’s look at Robert’s description of his experience in South Africa. On my first reading, I found some of his terms confusing. Here’s a quick glossary. I’ve linked most of the terms to a wikipedia or other page describing the term with more context and detail.

  • resus — Short for “resuscitation”, describes the activity and room in the hospital dedicated to resuscitating seriously injured patients.
  • HPA axis — The hypothalamus-pituitary-adrenal axis, an interconnection of hypothalamus, pituitary gland, and adrenal gland that is heavily involved in regulating stress responses and energy management.
  • EFAST — bedside sonoscope technology that uses ultrasound to assess internal body structures
  • FOAM — Free Open Access Meducation, medical education for anyone, anywhere, anytime
  • RSI — Rapid Sequence Intubation, a special process for inserting a breathing tube that is used where the patient is likely to breathe foreign material (like blood) into the lungs or otherwise seriously compromise their airway.

If you haven’t already, check out Robert’s story here (same as the link above). Then let’s examine how his experience with emergency trauma medicine can be generalized and profitably applied to stressful life circumstances for the rest of us.


As a consequence of his blog post about his experience in South Africa, Robert was invited to participate in a training program for Special Operations Combat Medics from eleven nations at the International Special Training Centre in Pfullendorf, Germany.

He presented his material there in four twenty minute lectures based on the theme of “Mental Toughness” (here are links to Robert’s four blog posts describing the material he presented). Robert writes, “A mentally tough individual is consistently able to produce desirable performances during moments of high stress.” Robert’s field is emergency medicine and when he says “high stress,” he’s talking about situations where a patient is likely to die if he doesn’t perform exactly the right actions quickly and precisely.

Most of us don’t experience that kind of stress on a regular basis, but we do experience stress because life isn’t consistently easy for anyone. Unexpected things happen. Sometimes those unexpected events can threaten our livelihood or finances or homes or loved ones, or sometimes they can just seem scary without offering any real existential threat, perhaps threatening no more than our self image or belief system but still throwing us off balance and degrading our ability to cope.

Given that we live life forwards and can’t see what’s coming, we often have to make a best guess as to how we should respond in the midst of stress and chaos. How can we train ourselves to have mental resilience, or toughness, to “consistently … produce desirable performances during moments of … stress?” That is, how can we teach ourselves to consistently live in a way we feel good about? What practices can help us live in a way that allows us to feel happy with ourselves?

Robert writes that a person is mentally tough if they are able to say two things:

  • “I am 100% committed,” and
  • “I feel challenged”

“One hundred percent commitment” may sound like the typical self-help pep talk that encourages the hearer to whip up artificial emotion and desire, or “passion,” to power one’s effort to make a million dollars or run a marathon or whatever the fashionable goal of the month is.

On the other hand, you are 100% committed to something. Maybe the sum of your commitment is spread across more than one endeavor and maybe your total commitment doesn’t feel particularly strong to you, but it all goes somewhere and if you gather it all up and look at it, that’s 100% of it. Where does it go? What is important to you? Whatever it is, is it important enough to be worth some intentional effort on your part to organize a purposeful strategy for protecting and expanding it? If you are uncertain where your commitment is, a useful activity might be finding out what it is.

“I feel challenged” refers to the two step assessment Robert describes consisting of the questions, “What are the demands of the situation?” and “Do I have what it take?” If I believe I do have what it takes, the result is a “challenge” mindset where my inner resources are recruited to respond to the challenge and my mind starts looking for ways to achieve the goal as quickly as possible with the least effort required.

On the other hand, if I believe I don’t have what it takes, the result is a “threat” mindset in which the “flight” response is activated, performance is degraded, visual and auditory pathways are narrowed (often experienced as dissociation), the mind may be filled with negative thoughts anticipating failure and defeat, and cognition becomes chaotic, making it difficult or impossible to prioritize responses effectively. One’s sense of fear is heightened, short term memory is impaired, and rational judgement is obliterated.

Robert’s suggestion is that we can use intentional strategies to convert situations that we have perceived as “threatening” into situations that we perceive as “challenging”. These strategies are designed to modify our perception of both the situation and our own resources so that we see our resources as adequate to the situation rather than as lacking. Robert writes:

“By using strategies to modify one’s perception of the immediate demands and available resources, we can convert threat appraisals to challenge appraisals, and in doing so, harness the power of the sympathetic nervous system, avoiding HPA axis-mediated self-sabotage.

I will propose seven strategies, over three phases of the game (the ‘practice’, ‘perform’, and ‘process’ phases), designed to favourably modify our perceptions during the cognitive appraisal process. The aim is to build the challenged mindset, resulting in a mentally tougher performer, better equipped for saving lives.”

My next post will outline the strategies and explore how they might apply to life in general, not just to the practice of emergency medicine.

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Posted by on 2017/10/07 in Uncategorized


What You Think Is Not My Business

Even if it’s about me.

My business is what I can do something about. I can’t control what you think.

All I can really control in this moment is what I think. And I can’t really even control that. Sometimes I can influence it. I can decide which thoughts to believe and which to let go of as they arise unbidden. I can’t control what my next thought will be, I can only watch for it and decide whether to believe it when it gets here.

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Posted by on 2015/11/30 in Uncategorized


The Feeling is the Payoff


What do you want? A new car? A new house? A new job? More money?

Whatever it is, it’s not really what you want. What you really want is the feeling you think those things will give you. All we ever really want is a feeling.

Consider: if you had the feeling already, would you care about actually acquiring the thing? If you felt the security and abundance of wealth, would you care what the number on your bank account actually was? And if you compare yourself to Jeff Bezos and feel poor, even having ten million dollars in the bank won’t be enough.

So where do feelings come from? They come from our thoughts — the ideas that we consistently hold and believe over time, the stories we tell ourselves. My thoughts, my stories tell me what events mean and my feelings automatically flow from those assumed meanings.

If I think bedtime means I have to stop playing, I’ll feel sad and angry and I may throw a temper tantrum.

If I think bedtime means I get to rest when I’m tired, I’ll feel grateful and happy and go to bed without resistance. Same circumstance, different thoughts, different feelings, different behaviors, different outcomes.

If I think money in the bank means I can go shopping, I’ll feel excited and happy. I’ll go to the store and spend the money. Then I may have thoughts and feelings about having no money in the bank.

If I think money in the bank means I’m building my wealth, I’ll feel happy, I’ll avoid spending money unnecessarily, and over time I’ll have more money in the bank. Same circumstance, different thoughts, different feelings, different outcomes.

If I go to visit my parents thinking, “They’re so old and out of touch. They don’t understand me. They have nothing to do with me. They’re boring,” I’ll feel bored and alienated. I won’t want to listen to them while I’m with them. I’ll leave as soon as I can. My relationship with my parents will be weakened.

If I go to visit my parents thinking, “I wonder what they’re up to these days. I wonder what I can do to help them. I hope they’re healthy and happy,” I’ll feel interested and curious to see them, hear them tell me their stories about their doings, share my stories with them, and do what I can to help them out. We’ll have a nice visit and our relationship will be strengthened. Same circumstance, different thoughts, different feelings, different outcomes.

In each case, it’s the thinking that makes the difference.

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Posted by on 2015/11/29 in Uncategorized


Think. Feel. Act. Have.

The first person I heard put those words together was Byron Katie. At the time, I failed to appreciate the full significance of this model of how life works. It wasn’t until I recently read Brooke Castillo’s explication of the idea in her book Self Coaching 101 that the full potential of the model became clear to me. Thanks, Brooke!

Actually, Brooke precedes “Think” with “Circumstance” because it’s often the circumstances of our lives that provoke thoughts. And often those thoughts are punitive or painful, leading to feelings we don’t like, actions (behavior) that don’t serve us, and outcomes we regret.

Brooke defines circumstance as “something you cannot directly control in this moment.” (emphasis in original)

I notice that the only think I have any influence over at all in this moment is what I think about whatever is going on. With the right thoughts now, I might be able to affect future moments, but this one now is already “in the can” as it were, out of my reach. It is what it is. So I have no leverage over current circumstance.

Feelings are automatic. I have tried to manufacture feelings before with a complete lack of success. I can’t make myself feel an emotion simply by trying. I have noticed, when feeling angry, that if I focus on the feeling, it fades. If I focus on what I’m feeling angry about (a thought), the feeling persists. So I can’t produce feelings directly, but thinking the right thought will generate a feeling.

It seems like I choose my actions, so it seems like I should have some leverage at “Act”. Maybe I do. But I notice that my past efforts to achieve outcomes by controlling my behavior have by and large not been successful. Sooner or later, I have to let go of my rigid control because I get tired or my feelings of deprivation overwhelm the willpower I’m exerting to avoid an undesired behavior or force myself into some activity that doesn’t interest me.

“Have” is the outcome that flows from my actions, my behavior. It turns into my circumstance for the next iteration of the model. It triggers more thoughts which, negative or positive, helpful or painful, lead to more feelings, more behavior, and further outcomes. The outcome is an automatic consequence of the behavior.

So the only place I have a real chance to affect the flow and generate lasting change is at “Think”. To do so, I have to watch my thoughts closely and notice how they condition and shape the downstream feelings, how the feelings generate the behaviors, and how the behaviors produce the outcomes. Then I need to consider which thoughts will lead to feelings, behaviors, and outcomes I like better than the ones I’m getting.

If I’m happy with how I feel, what I’m doing, and the outcomes I’m getting, I’m already done. Nothing more is needed. In any situation, the feeling is the payoff. The only reason for ever changing anything is because I don’t like how what I’ve got feels.

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Posted by on 2015/11/28 in Uncategorized


Salvation. Liberation. Enlightenment.

Whatever you want to call it. Awakening. Realizing the Nature of Things.

It’s what we all ultimately want — the ability to live in a comfortable and satisfying way, help and care for those we love, shrug off the shit that life dishes out, and carry on with aplomb and a modicum of enthusiasm.

Religion tells you that you can’t get it on your own, that you have to have Jesus’ or Mohammed’s or Buddha’s help. Never mind that those very guides taught responsibility and thinking for oneself (at least that’s my story and I’m sticking to it). Subsequent interpreters, clergy, theologians, imams, Zen masters, and grand poobahs will tell you that you need their interpretations to really understand what the heavies said.

I say you don’t need the interpreters or the heavies. Life shows you how it is to be lived. Treat others the way you want to be treated. Take care of things that need attention while they’re little and easy so they don’t get big and difficult. The universe is not about you — don’t take it personally, either the good stuff or the bad stuff. It’s just stuff.

Waking up (being liberated, being saved, enlightenment, etc.) is just a matter of recognizing that you are a process of awareness operating in a body. The body (with its brain) is the computer and you are the program running on it.

The physical matter that we can interact with is around 2% of the universe. No one knows what the rest of it is (yet — scientists are working on it). In one small, insignificant corner of space, a small fraction of this 2% has somehow organized itself into devices that have become aware of themselves, that can think  and dream and experience sensations and feelings. Whatever story you choose for explaining this to yourself (god, the big bang, elephants and turtles, whatever), that’s amazing and awesome!

Pay attention and enjoy the ride. As far as anyone has been able to find out, it’s one to a customer. Some of the stories claim there are repeats and/or an eternal life after this temporary one. Sadly, hard data to support such stories is lacking. So it behooves us to pay attention this time around and get the most out of it we can. The only time you can pay attention to is now. The only place you can pay attention to is here. Get to it.


Posted by on 2014/08/09 in Uncategorized