The importance of self-awareness

I often think of The Great Gatsby. While everything in it has been said before, it seems like a particularly easy-to-understand piece on human nature – not least because it seems to be reflective of what our society looks like almost 100 years on. Gatsby was great because he was motivated by love and incredibly focused and resourceful in his quest. There were also many reasons why he wasn’t great: he lied about his origin, he lied about his name, he was a criminal, he had no problem seducing a married woman with a child… Most of all he got carried away from reality. He didn’t see Daisy for who she really was even though it should have been obvious. He suffered from infatuation, limerence and obsession.

why self awareness is important

There’s an interesting dichotomy that arises from obsession. On the one hand, it is a way to get motivated like nothing else. I was recently listening to an interview with Travis Kalanick, the CEO and co-founder of Uber, who talked about how he chose his idea. He said he was in love with the idea of Uber. He also said that after you fall in love with your idea the hard part is to adjust it to the world so that it is exactly the best it can be. It seemed that all great entrepreneurs develop their businesses for some kind of personal reason. Mark Zuckerberg said that Facebook was something he would have wanted to use for himself. He seems fascinated with how people have huge areas of the cortex dedicated to deciphering the meaning of facial expressions, seemingly minor detail. The kind of motivation that’s required to spend every waking hour you’re not doing coursework in one of the top universities working on social websites means intense interest. Whether it is obsession or not, it’s close to it. Our culture seems to value obsession. In fact, the word has connotations of real dedication and martyrdom. There are gyms called Crossfit Obsession. A “normal” person couldn’t have the level of dedication that these entrepreneurs have, or a particular variety within the men and women of Crossfit – we’ve all met them. A healthcare professional would surely class them as having traits of OCPD, or find a way in which their activity is a form of escapism.

However, all great entrepreneurs are sufficiently in touch with reality so as to know how to adapt. This brings me to the second part – obsession needs to be balanced with reality. For anyone who knows the feeling, they know that this is much easier said than done. When one tries to reflect on reality, it is easy to slip into denial. Alternatively, it can be easy to see the flaws, decide that you obsession is silly and give up on it. It is much harder to see the flaws and incorporate this information meaningfully into your quest.

This idea of either idealising or damning your quest first came to me when I was dealing with patients who had emotionally unstable personality disorder as a doctor. People with EUPD tend to undergo something called splitting: something/someone is either perfect, or they aren’t worth thinking about at all. In fact, this is characteristic of many personality disorders. For example, people with narcissistic traits are very quick to decide that someone’s opinion is worthless if they don’t like something about this person.

self-awareness-is-the-key-to-success

How is it that some people are able to benefit from the momentum of obsession, but not dragged down by the unhelpful ignoring or reality or give up on their idea at the first sign of imperfection?

Are these great entrepreneurs necessarily all free from toxic personality traits? Not at all. It must be possible, however, to be sufficiently self-aware so as to let those parts of your personality that you need the most at a given moment to fully express themselves. After all, all these personality traits that we regard as vulnerable – and put them down as traits of personality disorders – evolved for a reason. They made sense in a context. They are only called abnormal because they stopped being adaptive when the environment changed, but the person who developed them lacks the self-awareness required to acknowledge that they are using legacy software – never mind adjust again. So it’s not like there’s just one personality type, not one strategy that will carry you through, but like Darwin said – it is the most adaptable that makes it through. Adaptability is completely a function of self-awareness.

So, how could we hook up with some of that self-awareness? My hypothesis is, as always, by paying attention to it. It is surprising how commonly people are unable to describe how they feel. How do you feel right now? Is it easy for you to answer? In normal life – and in psychiatry – I’ve met pretty high functioning people who are unable to answer that question. Really and truly, they look at you like you are an alien, look away and after about 10 seconds they say, I don’t really know. It’s obviously a spectrum and it’s not uncommon. Some of these people will try and assess how they should feel, making cognitive judgements about their circumstances. It’s called alexithymia. I think this is the first step. Ask the question – how does it feel? Putting words on it is a good place to start. Tackling physical sensations first could be an even better idea. When you notice that you are hungry – how does it feel? Is there a pain in your abdomen? Where? What kind of pain? Is it a cramp or a dull ache? Is there some nausea that comes with it? Does your abdomen feel warm or cold? Essentially, it is a form of mindfulness. With some practice it will be easier to put words on your feelings, or your inner state. It’s not a case of needing to soul-search. It’s not cognitive, it’s all about feelings. Whether we like it or not, emotions play a decisive role in our behaviour – they give rise to our behaviour, that’s what the word means. I think that mindfulness has the potential to increase self-awareness like no other instrument at our disposal. Mindfulness is known to increase empathy. Self-awareness is no less important. People who lack empathy are probably lacking insight into their own feelings to begin with. It may even make sense to think of self-awareness as a form of inner empathy.

If there was one thing that I think would advance someone’s personal development by leaps and bounds – it would be self-awareness. It doesn’t matter that you aren’t the strongest, the tallest, the smartest – or whatever, but if you able to be sufficiently self-aware so as to surround yourself with the right people – you can compensate for those weaknesses – and focus on your strengths.

When the going gets tough

A few days ago, for the first time in years, I found myself in a horrible mood – completely out of the blue. On reflection, I got into it through comparing myself to someone else, being inflexible and impatient under the pressure of my own big dreams. Had I not known better, I would have thought I was suicidal. I was thinking of how I owe it to the people who love me to keep going. I knew that I felt like this before. Because of that, cognitively, I knew it would pass. Cognitively, I knew that the kind of words that were floating around in my head were only words that clumsily tried to explain how much pain I was in. All the same, it was a really dark three or four hours of self-hatred and hopelessness. It was made worse by the vicious cycle of feeling guilty and weak for feeling bad.

Cognitively, I knew that the faster I interrupt this horrible mood, the better. Bad moods beget more bad moods. At this point, I stopped judging myself for feeling bad, acknowledged that this is simply the way it is – good or bad – and it’s time to get myself out of this horrible state. But how? How do you get yourself out of this mood swamp? Common wisdom would say: look for support. I couldn’t fathom talking to anyone. I know now that it’s silly, but there was no arguing with the upset-me. Common wisdom would say: try and feel grateful for what you have rather than feel bad about what’s missing. That just seemed like some kind of evil joke.

I want to die

The answer, as always, came from asking the right question. The question I asked was: What’s useful about this? I knew this lesson from before. I’ve even written about it here. It just goes to show that these lessons aren’t only cognitive. It takes time and iterations to learn them. Even with all my knowledge, it took me a bit of digging around to find where the right button was.

What was useful about it? I knew that I need time to look after myself. In and of itself, that was useful information. I looked back and wondered what upset me – I learn from that too. It wasn’t the first time that being super focused and not flexible enough got me into trouble like this. However, rather than judging, I will just take this is another data point and another note to self: be more flexible. This is high level theory, but I’ve already implemented measures that would make it easier for me to be more flexible. I also realised that today wasn’t a good day to do any work. My alarm bells went off – I am glad that I don’t have to work?! Rather than accusing myself of laziness, I dug deeper. I was doing something  important, repetitive – and boring. It was super easy. I am sure many people don’t mind those kind of tasks, but I can’t handle them at all. My relentless focus on doing what needs to be done got me into a situation where I couldn’t play to my strengths. So here’s another lesson: doing things that don’t come naturally for too long isn’t sustainable. I think that’s valuable as next time I will be able to assign who does what and when better.

As I am writing this, I am able to not just hope that that horrible feeling never happened – I feel grateful that I learnt from it. I really mean it. It’s all about learning, progress, small wins and getting closer to the person you want to become. And not judging.

The truth is, it’s highly unusual for me to get upset. I wasn’t just born this way though. There was one thing that made me go from super sensitive to where I am now. When I say super sensitive, I mean if the person who poured my coffee in the morning looked at me wrong – I would feel uneasy for hours. What made the difference for me wasn’t some sort of soul searching or even mindfulness – it was straight up physical exercise. I don’t know whether it is just the flood of endorphins, but it really helps with the art of just not giving af when appropriate. Exercise is the one thing that makes the biggest difference to both mental and physical health for a healthy person.

what to do when you feel awful

There was some cognitive work too, but it would never have happened without the initial boost through exercise. The cognitive work was something like this: the barista doesn’t care about you, you are just a person with an order and a wallet. They are in their own world. It’s not personal. They are just trying to get through the day the best they can. I think there’s a word for that – it’s called empathy. Exercise isn’t known to cause empathy, what’s going on here? Exercise requires focus, so in a sense, it requires mindfulness. Maybe that’s part of it. In any case – in my unblinded non-randomised non-controlled trial of n=1, it works.

What having no idea about psychiatry is like

In all my time in medicine, psychiatry was certainly the steepest and most unexpected learning curve.

The truth is that I started off as a pro nerd who wanted to be a surgeon. When they said medicine is an art and a science, I was just waiting for them to stop. In medical practice, choosing an antihypertensive drug is not an art. Perhaps, looking for new mechanisms of action is more creative, but not the practice of prescribing. There are scientifically rigid algorithms on how it should be done as of today, and the rest is harmful heresy – not art.

a medical student's journey through psychiatry

When I was in first, second and third year of medicine, I was convinced I wanted to do general surgery. Possibly paediatric. I took serious steps to that effect. I found a family friend who was a surgeon, and aged 19, I was spending my summers doing 36 hour shifts of shadowing surgeons. Scrubbing in on critical abdominal aortic aneurism ruptures, appendectomies, cholecystectomies, you name it. I learnt much faster in those 3 months of summer than surgical trainees in their cursus honorum residency.

At that time, I was shaping up to become a pragmatic and practical surgeon. We all know the kind of culture that is prevalent among surgeons – especially 10 years ago. Needless to say, it rubbed off on me too and I was expecting psychiatry to be a wishy washy waste of time. There was no stigma, no prejudice, no resistance – just an expectation of something I will have no interest in.

Then my college experience of psych began. I recall being late to the first lecture and sitting down at the back with one purpose only: make sure I am signed it. I wasn’t expecting to learn anything other than a bunch of genetics concerning schizophrenia and Alzheimers and be lectured on good communication skills.

I was so wrong.

My attention was instantly captivated by the lecture. It had nothing to do with the lecturer: he was ok, but it’s not like he was ultra captivating, charismatic or whatever. It was the substance of what he was saying. The lecture was on something called phenomenology (the study of subjective experiences). So for example, I learnt what the difference is between an illusion and a hallucination. What knight’s move is. Perseveration. Running commentary.

It was fascinating. It was like a parallel universe just opened up to me. I was entirely unfamiliar with all of these things. No portrayal of these phenomena in films comes close to actually considering what it is like, never mind meeting a person who suffers from such a thing. Maybe A Beautiful Mind is a place to start. But still, it barely, I mean barely, scratches the surface. I was in the industry, I was top of my class and yet until I went and properly exposed myself to it – I was so so ignorant. It is important to realise that the general population, no matter how educated, has absolutely no idea what a person with a severe and enduring mental health problem goes through. Zero.

psychiatry as an art

As a fervent advocate of the scientific method, I would like to point out the role of art in this. It’s not art in some kind of mystical, deeper meaning sense. It is art in the sense that it is creative. Surgery is creative – but in a practical sense. It’s just a more conservative field.

Psychiatry is cognitively creative. It’s not algorithmic like most of medicine. Much of it has never been done before. The DSM differs so much edition on edition, that it is clear that we haven’t even come close to understanding what’s really going on. Paradoxically, the actual practice of psychiatry is quite intuitive 90% of the time.

Ten percent of the time, though, psychiatry requires a doctor to think outside the box in another dimension. Because you cannot MRI someone’s brain and say – this is mercury poisoning, not dementia. This isn’t depression, this is catatonic schizophrenia. You really need to not just think, but rely on something less tangible – does it feel like this person is depressed or does it feel like it’s EUPD? Freud tried putting all kind of names on these intangible feelings. It’s just a first attempt. Is it possible that both of these diagnoses are missing the point of what’s really going on beneath the surface and in another 20 years the DSM will have neither of those in it? If House solves puzzles, this is solving puzzles when you have no idea what the resulting picture is going to be.