Doctors have already proven their worth. We have succeeded beyond what most of the population will achieve. And yet, there are certain goals we cannot seem to achieve. And the worst part is that we know we could do it, and the person getting in our way is someone we know well. We look at her in the mirror every day.

You want to lose weight, but it doesn’t last past the donuts on the ward.

You want to write that article, paper, grant, but you procrastinate until you have made yourself miserable.

You resolve that “this time, I will really do it.” And then you don’t.

So what is wrong with us? Nothing, really. We self-sabotage because it works. Our brain is led by the “motivational triad.” We want to seek pleasure, avoid pain, and do it in the easiest way possible. These principles have increased the odds of our survival.

Pleasure comes to us courtesy of dopamine. This chemical boosts our reward center and brings us back to things that give us a hit of pleasure. And there are so many things that give us pleasure: food, sex, alcohol. A study noted the dopamine hits just by looking at something that gives us pleasure. How unfair is that? We are behind before we even start. Our only hope is to use the power of our prefrontal cortex and plan ahead. And not just plan ahead, but do it as specifically as possible and ahead of time. For example, “I will plan what I will eat tomorrow, not have anything off plan, and I will have a plan to remind myself before I hit the ward where there might be a temptation.” You could have your own dopamine hit available- a reminder of how you will feel when you achieve your goal.

Our thalamus detects threats, and the amygdala activates the fear response, and our sympathetic nervous system kicks into gear. Stress hormones work to keep us safe by removing us from the threat or causing us to “play dead.”

We self-sabotage when the goal we are trying to achieve feels more like a threat and less like a reward. The threat isn’t the lion in the jungle anymore, it’s psychological threats like rejection, discomfort, stress, sadness, and anxiety. And we would do anything to not feel these things. So we avoid. We seek pleasure in dopamine hits.

In her book, Stop Self-Sabotage: Six Steps to Unlock Your True Motivation, Harness Your Willpower, and Get Out of Your Own Way, Dr. Judy Ho describes the four elements that fuel the conflict between going for your goals and being held back by perceived threats that actually won’t harm you:

• Low or shaky self-concept
• Internalized beliefs
• Fear of change or the unknown
• Excessive need for control

These LIFE concepts could help provide answers to why you may self-sabotage. They tell you about how you interact with the world.

Self-concept is your image of who you are and how you define yourself. For example, you could plan a running schedule you found online. You have the goal of running a marathon. But what happens if you don’t want to run one morning? The pain of getting up in the morning exceeds the reward of finishing the marathon. You are likely to be more successful if you change from an act you do (run this morning) to a stronger self-concept (I am runner). If you have a strong self-concept and identify as a runner, you can rely on the image you have developed of what a runner is. A runner is someone who follows their plan, knows there will be discomfort, and remembers that this is a part of a bigger reward and worth it. If you have a shaky self-concept, you may not see yourself as a runner. The doubt lives below the surface, and it would not take much to convince you to skip the run.

Internalized beliefs are when we learn through conditioning and our environment. If your mother was hesitant to travel because the plane may crash and strangers lurk at every corner, then you may be hesitant to take chances that would involve travel. If you had a malignant residency where you always felt judged, it would be difficult to approach a surgery without waiting for the threat you feel is coming.

Fear of change or of the unknown means you are stepping outside of routines, familiarity, and comfort. This can make the brain work hard and violate the motivational triad concept of keeping things simple. If our brains get overloaded, we may be too overwhelmed to do anything productive. Look at that nice, comfy, easy spot under the bed. Wouldn’t that be better?

Excessive need for control, unlike those noted above, is more likely innate. If we have more control over our environment, we are more likely to survive. But if you are planning big things, new things, then you are unlikely to see the finish line. And if you need to see what will happen, that may keep you from starting at all if you aren’t sure what the goal line looks like.

Awareness of these pitfalls is the first step. Truly exploring your current and past situations will help reveal the origin of your psychological threats. Knowing what feels threatening to us will help us find the key to reassuring our brain that we are safe. The feeling is nothing more than a warning sign asking if we are safe. When we know we are safe, we will know that the discomfort of trying to achieve what we want in the world is not a threat to us. Discomfort is necessary to achieve at our highest level. We simply learn how to live with discomfort.

Amy Vertrees is a general surgeon and founder, BOSS Business of Surgery Series.

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