Know When to Apply the Brakes

STRENGTHEN YOUR BRAIN’S INTERNAL CONTROLS

The art of leadership is saying no, not yes. It is very easy to say yes.

—TONY BLAIR

On a recent trip to Maui, I watched a fascinating interaction between an assertive four-year-old, red headed girl in pigtails and her mother. I was having lunch at a café overlooking the Maalaea Harbor at the Maui Ocean Center. It was a warm, serene day, with a light tropical breeze. The sea was calm. Then, in a flash, a storm erupted at the table next to me. Reaching for her camera, the mother accidentally knocked over a glass of ice water. Her little girl squealed with excitement, probably because she was the one who usually spilled the drinks. The mother was obviously embarrassed. As she started to mop up the water, the little girl gleefully started to play in it with both hands. Sternly, the mother told her to stop and put her hands down at her sides. But the little girl wanted to play in it, so she didn’t listen the first time. The mother repeated her warning, this time with a consequence attached. “One more move toward the water,” the mother said, “and I am taking away your baby dolly.” This caused the girl to retreat quickly. Her baby doll, also with red hair, was more important to her than the momentary pleasure. I had seen her playing with the doll before the water incident. After a few seconds, however, I could see the temptation of the water was starting to build in the little girl’s brain. The tables were made of a rough stone top and the water formed little pools with the ice floating like miniature ships. It just seemed like too much fun. The little girl sheepishly looked at her mother to see if she was watching. When she saw that her mother was distracted with the cleanup effort, the girl slowly started to move her stretched out little fingers toward the water. It reminded me of the struggle between good and evil we all face. Do I inhibit my impulses and do what is right? Or do I do what I want in the moment? Which one would win on this gorgeous Maui day, I wondered? There were competing interests. Maximum fun or maintaining possession of a beloved baby dolly? “She is only four,” I thought to myself. “Her (PFC) has barely started its long trek toward maturity.” As it turned out, the mother mopped up the water with the help from an attentive waiter and the little girl was saved from her impulses. Her dolly’s freedom was safe, at least for the moment.

Unfortunately, we are not all so lucky. At some point our mothers let us go and we are left alone with our impulses. What we do with them is a major determinant of our success or failure in life. Being successful is as much about inhibiting actions as it is about starting or maintaining them. A car without brakes is a death trap. A life without brakes, even with great passion, is likely to end early in failure. Passion is important to fuel our success, while clear goals help steer us in the direction we want to go. To stay on track we also need good brakes to modulate our movements, to slow us down when we are going too fast, to stop us when we get the urge to take a detour or go in the wrong direction. Weak brakes cause us to crash, while brakes that are too sticky impede our progress. This chapter will discuss a critical function of the PFC in regard to a magnificent mind—the ability to say no and control our impulses.

Prefrontal Cortex—Master Brakes

As discussed earlier, the PFC is involved with higher functions, such as planning, forethought, and impulse control (see Figure 11.1). The PFC also helps us to modulate emotions, keeping us from getting too high or too low. As it does not fully develop until we are in our midtwenties, we see children and teens being much more emotional. When I walked through the door at home after a day at work when my children were little they would run to greet me with wide open arms and lots of excitement. When they were disappointed, they might cry crocodile tears. As they got older, their emotions were under much better control, plus I was not nearly as exciting to them as teenagers.

Figure 11.1: The Prefrontal Cortex

When there is damage to the PFC, people often lose tight control over their emotions. James Brady, President Reagan’s press secretary, offers a dramatic example. On March 30, 1981, when John Hinckley attempted to assassinate President Reagan, Mr. Brady was shot through his frontal lobes. Not only did he suffer paralysis, but he also had personality changes and became more emotional. His highs were too high and his lows too low. He said during an interview on television that when he was a little sad, he might start to weep uncontrollably or if he heard something that was slightly funny he might start to laugh as if it was the funniest thing he had ever heard.

Healthy activity in the PFC is associated with conscientiousness; abnormally low PFC activity is associated with carelessness, inconsistency, troubled decisions, and impulsivity. In reviewing 194 studies researchers from the University of Illinois at Urbana-Champaign found that increased death rates were associated with such impulsive behaviors as tobacco use, diet and activity patterns, excessive alcohol use, violence, risky sexual behavior, risky driving, suicide, and drug use. A healthy PFC is essential for a long and successful life. Abnormalities in the PFC can be the result of inherited conditions, such as ADHD, or be the result of damage from brain injuries or toxic exposure. It can also result from poor training or overly permissive parents.

The Short Pause: How Weak Brakes Sabotage Our Lives

Saying no to the urges of the moment is often more important than saying yes, even to positive actions. It takes only a moment, a pause, to reflect on the consequences of our actions to see if they are in our overall best interests. When the little girl paused before she gave in to the urge to splash water all over the table, she was allowed to keep her doll. When you pause before saying yes to the urge to cheat on your spouse, you are more likely to keep your marriage intact. When you pause before saying yes to the urge to tell off an irritating customer, you are more likely to keep your job. When you pause before taking money illegally out of the company coffers, you are more likely to stay out of jail. When you pause before saying yes to volunteering for a project or taking on work that is not directly related to your own goals, you are more likely to stay focused and be successful. Having the short pause, to think through an intended comment or action to decide if the behavior fits your goals, is a PFC function and a major key to success.

Impulsivity, an inability to inhibit behavior, is at the core of much of the personal failure I have witnessed over the past three decades as a psychiatrist. I have seen many people who exhibited impulsive behaviors, such as murderers, robbers, rapists, pedophiles, wife beaters, child abusers, compulsive gamblers, sex addicts, drug and alcohol addicts, bulimics, road ragers, thrill seekers, unfaithful spouses, and countless others. I saw a ten-year-old boy who impulsively tried to jump on a moving train, imitating scenes from movies, only to slip as he tried to grab the ladder and have both legs amputated by the large steel wheels as he fell underneath the train. I saw a man who impulsively stabbed others for no reason. I saw him only when he was shackled. And, I saw a woman who would get in cars with men she didn’t know to have a good time, just because she was invited.

Thoughtless words and actions, again and again, have caused harm to careers, relationships, and how we feel about ourselves. Impulsivity is at the root of many political scandals, sexual harassment issues at work, and fiscal irresponsibility on the job or at home. Let’s look at each area listed in the One-Page Miracle to see how impulsivity can sabotage lives.

RELATIONSHIPS

People who struggle with impulsivity often say thoughtless, hurtful things that negatively affect their relationships. Many of my patients with ADHD, for example, play this relational game I call “Say the First Thing that Comes to Your Mind.” Some even wear it as a badge of pride. “I am brutally honest,” they say. I usually reply that it is usually not helpful. Healthy relationships require tact. They require us to inhibit the first thoughts that come to mind. Once, I walked into my waiting room to greet an eight-year-old patient. I was about ten minutes late for the appointment. When she saw me she said, “Well, it’s about damn time.” Her mother looked horrified and apologized for the little girl’s comment. Living with ADHD loved ones myself, I knew comments like that were just part of the terrain. This game causes many, many problems. When you just say the first thing that comes to mind, you can hurt someone’s feelings or give away secrets that were entrusted to you. One of my patients was given the task of bringing a friend to his surprise birthday party. On the way to the party my patient inadvertently started talking about how much fun they were going to have at the party. When he saw the look on his friend’s face he was horrified that he had ruined the surprise.

In addition to saying thoughtless, hurtful things, weak brakes are also associated with frequent interruptions. When someone who struggles with impulsivity gets a thought in his head he feels like he has to say it, rather than waiting for the other person to finish her thought. He believes his point is so important that he just can’t wait. Once, in a couples session, when I pointed this behavior out to a woman whose husband was very frustrated by their poor communication, she said she had to say what was on her mind or she would forget it. It also meant that she wasn’t listening to him. I gave her some paper to write down the thoughts she was afraid she’d forget, so her husband could complete a thought.

Other types of impulsivity that hurt relationships include:

• Calling people bad names

• Lashing out in anger

• Throwing tantrums

• Exhibiting unpredictable behavior

• Answering cell phones or text messages in the middle of having an important conversation

• Having affairs

• Saying yes to more projects at work that take you away from home

• Becoming involved with Internet pornography when you know it hurts your spouse and takes sexual energy away from her

• Lashing out, hitting, or belittling children when they irritate you

Impulsivity often ruins work relationships and job potential. Saying thoughtless, hurtful things to co-workers, vendors, or customers has gotten many people terminated. Stealing, sexual indiscretions, drinking on the job, using Internet access at your workplace to look for another job are just a few examples. Impulsivity behind the wheel has caused drivers their lives.

WORK/FINANCES

As an employer, I have often thought about doing brain scans on the people I hire. I have never made a hiring decision based on a scan, but sometimes I wish I had. Eventually, most people who work at the Amen Clinics get scanned, either out of curiosity or because they are going through a difficult time, such as postpartum depression or have suffered a head injury. The results have been very consistent. The people who have worked for me who had low PFC activity tended to get into the most trouble, by being late, saying thoughtless, hurtful things to co-workers or patients, making careless mistakes, procrastinating on their tasks, or getting into trouble with the law. They also tended not to last long.

I once treated a doctor who was fired from his county mental health job in San Francisco. It usually takes a lot to be fired from these jobs because psychiatrists are hard to find. One day he had a patient at 1 P.M. When his clinic administrator called him at 1:30, because he still had not arrived at the clinic, he told her that he was playing golf in Oregon. He had forgotten about the appointment. That was the last straw. He was fired. A scan revealed he had very low PFC activity.

Finances are often ruined by impulsivity. One of my first patients came to me thirty thousand dollars in debt. She knew her husband would be furious. She had a shopping addiction that she felt she couldn’t control. I have seen many patients in trouble with the IRS because they did not plan for their taxes. The IRS does not care if you have a brain problem as the reason for delinquency. Its agents tend not be impulsive but rather compulsive.

SELF

Impulsivity hurts our emotional, physical, and spiritual lives. It is often involved in many psychiatric disorders, such as ADHD, addictions, and temper problems, which erode self-esteem. It is involved in eating disorders like bulimia and obesity. “I’ll just have one or two bites of the chocolate cake,” for some, turns into eating the whole cake. Impulsivity causes us to give up too quickly when exercising or meditating (I’ll do it later), and is often involved in sin, which I define as doing what you know is wrong, according to your conscience.

When the Brakes Come Off: Prozac, Crazy Sex, and Costa Rica

Sometimes impulsivity can be triggered by taking a medication that lowers your PFC. Kimberlee was hurting. She was going through chemotherapy for thyroid cancer and felt overwhelmed, tired, and depressed. In her mind, at age twenty-six, she was supposed to be healthy. She was supposed to be at her best. Yes, she had struggled from an eating disorder in her teens and early twenties, but she thought that she had gotten beyond it. Now this nightmare. The hopelessness, lack of energy, and beginning weight gain from the thyroid dysfunction were too much to bear. She started purging again and thought her life was over. Who would ever want her, bulimic, fat, depressed, and with cancer? She was a woman who was desired for her looks. She had long, thick, flowing, dark red hair; soft peach skin; high cheekbones; the face of an angel; and what others would think, but never her, a perfect body. None of that mattered in this moment. Kimberlee felt anxious, panicky, sad, and hopeless. She couldn’t sleep but spent days fretting in bed. On the advice of a worried friend, she saw a local psychiatrist. Kimberlee was hesitant to see the doctor, but she was so tired of feeling bad.

After filling out a few pages of information and spending forty-five minutes with the doctor, Kimberlee left the office with a prescription for Prozac at a fairly high dose. She wondered how he could know much about her in that short period of time. He mentioned something about situational depression and the need for the high dose of Prozac to deal with the eating disorder. The appointment was a whirlwind and she was unsure about all that he said. She did remember his saying that the medication had few side effects and she should start to feel better in a week or two. With the hope of feeling better she started the medication.

Within a few days she started to feel much better. Her energy improved and she started to feel optimistic once again. She started going out with her friends and became more social. “How strange,” she thought. “I feel great because of a little green and white capsule.” Over the next few weeks she felt better than she ever had. Her worries were dissolved and she looked forward to new adventures.

She went with friends for an evening of fun at the Beverly Hotel in Los Angeles. There she met an interesting fifty-year-old man, Mark, who was obviously captivated with her. He invited her to his home in the Hollywood Hills. Within three days Mark invited her to go with him on a trip to Costa Rica. To her own surprise, she agreed, which was completely out of character for this woman who had been fairly shy her whole life. When she questioned her own judgment about going to a foreign country with a man she had just met, she thought, “What the heck, it is time to start living.”

She had a great time on the trip. Mark was fun and uninhibited. She felt as though her depression and worries were from a lifetime ago. One night in a bustling Costa Rica strip club after a few glasses of wine, Kimberlee found herself feeling so good that when Mark put his hand on her inner thigh it sent eclectic sexual feelings to her inner pelvis and up her spine. She leaned into Mark, moaned encouragement, and kissed him passionately. Feeling her responsiveness, Mark brought his hand between her legs and stimulated her directly. With her eyes closed, Kimberlee was totally focused on the pleasurable feelings. Her sounds of satisfaction started to fill the club. Soon everyone’s eyes were turned toward her as she came to orgasm. When she breathlessly became aware of her surroundings, she became embarrassed and started to feel horrified by her very public behavior.

Mark did not turn out to be a good guy for Kimberlee. He left Costa Rica early the next morning, leaving a plane ticket on her nightstand. Feeling ashamed of herself, she boarded a plane to Miami on her way back to Los Angeles. On the first leg of the flight she sat in first class. When the pilot walked by her seat, he smiled at her. Kimberlee was too tired and too upset to care. The stewardess in first class told her that the pilot would love to meet her. After several attempts to say no, Kimberlee agreed to have a drink with him at the Miami airport.

They hit it off and drank several glasses of wine and talked for hours. When he invited her to his hotel room, she went. They had passionate, intense sex all night. On her flight home the next day, she began to hate the person she was becoming. What happened to her judgment? Her morals? Her good sense?

Connecting the change in her behavior to starting Prozac, she stopped the medication and on the advice of a friend came to see me at the Amen Clinics. When I saw Kimberlee it was clear that the Prozac had disinhibited her. It took the lid off of her judgment and impulse control, as well as her internal moral compass. When we performed SPECT scans of her brain off the Prozac, they showed us that, in fact, Prozac was the worst possible choice for her. Her scans showed low activity in her PFC. Her internal supervisor was weak and could not control the passions of the moment. It could not see long-term consequences.

Prozac and medications like it, called selective serotonin reuptake inhibitors, increase the availability of the neurotransmitter serotonin in the brain, which helps to calm the brain. Prozac is most effective for people whose PFC works too hard, causing them to be inflexible, worried, obsessed, and rigid. When Prozac works, it helps calm the PFC to help people feel more relaxed, happier, and less anxious. If the PFC is already characterized by low activity, however, giving Prozac to someone like Kimberlee lowers her PFC even further, thereby disinhibiting her and causing serious problems in her life. Kimberlee needed her PFC stimulated, not relaxed. How would the doctor know unless he looked? Images 11.2 and 11.3 show a depressed woman’s brain before and after Prozac. Notice the marked decreased PFC activity.

Image 11.2: Before Prozac

Image 11.3: After Prozac

As I wrote in Sex on the Brain, the brain is a sneaky organ. All of us have weird, crazy, sexual, stupid, unhelpful, dishonest, hurtful, even violent thoughts. Thankfully, our PFC inhibits these sneaky thoughts and prevents us from saying them or acting upon them. When this part of the brain works right we can laugh at or dismiss these sneaky thoughts. When there is dysfunction, damage, or disease to this part of the brain, these hurtful, embarrassing thoughts surface in our behavior.

Subtle Ways That Weak Brakes Can Sabotage Success

In Jim Collins’s best-selling book, Good to Great, the hedgehog concept is one of the major principles behind why companies go from good companies to great ones. The concept is about razor-sharp focus. The idea for this principle came from Isaiah Berlin’s famous essay “The Hedgehog and the Fox” that divided the world into hedgehogs and foxes, based upon an ancient Greek parable: “The fox knows many things, but the hedgehog knows one big thing.” Those who led less effective companies tended to be foxes, never gaining the clarifying advantage of a hedgehog, being instead scattered, diffuse, and inconsistent. Too often business, family, or personal leaders are involved in too many activities and get distracted by the excitement of the moment, which takes time and attention away from their primary goals.

In a similar way, General Electric’s legendary CEO Jack Welch became famous for a particular business strategy. If the company was not No. 1 or No. 2 in a market and could not get there in a short period of time, he sold or closed the business unit, even if it was making money. He wanted the company to achieve total focus on what it did right to optimize their efforts. During his twenty years of leadership at General Electric, Welch increased the value of the company from thirteen billion dollars to several hundred billion. Weak brakes impair our focus and get us involved in many different things that have little to do with our goals.

A lack of clear focus and being distractible causes us to say yes to trivial or less important activities, which robs time and energy from more important ones. Raccoons with shiny objects come to mind. I had two pet raccoons growing up. Whenever these furry, masked creatures saw something shiny they had to explore. This is where our new technology is scattering our attention and focus. As we pop on the Internet to do our work, many of us must first check out our news pages, see who has e-mailed us, turn on the music and download a song or two, see if our Internet dating sites have produced anyone interesting, and then get ten instant messages from friends who are also on. It often takes people half an hour or more to get to their work. Many also leave their e-mail notifications on while working, so they are constantly interrupted. These interruptions erode our brakes.

Strengthen Your Brakes

Whenever you give in to your impulses and lose your focus, you actually weaken the PFC’s control over your life and make the behaviors more likely to occur again. When you resist negative behaviors you strengthen the PFC and your own self-control. Resisting the temptation to waste time or engage in activities that are worthless or harmful makes you stronger. Repetitively doing positive activities makes them more likely to occur. Disciplined behavior increases discipline.

Psychiatrist Lewis Baxter, in a series of breakthrough experiments at UCLA, found that when he prevented obsessive-compulsive-disordered patients from engaging in their senseless repetitive thoughts or behaviors it actually changed the brain’s function in a positive way, working in a way similar to medication. Changing your thoughts and behaviors changes your brain. Give in to useless behaviors and you are more likely to keep doing them. Engage in more useful behaviors and you will be more likely to continue them. Your moment-by-moment actions program your brain’s actual function.

It starts early in life. As I mentioned earlier, when you allow a child to whine to get their way, you actually teach the child’s brain to whine. When you give in to a temper tantrum, you teach the child’s brain to have more tantrums as a way to get what he or she wants. Giving in to bad behavior disinhibits behavior and weakens the PFC, as the child does not have to exercise any self-control. The brain is like a muscle, and the more one uses it, the stronger it gets. The brain, also like muscles, has memory. Giving a child clear, consistent, reasonable consequences for negative behavior while reinforcing positive behaviors enhances development in the PFC. So many behavior problems in children are due to erratic or absent parenting. The lack of effective parenting sets children up to have problems their whole lives. Parents act as a child’s PFC until his or her own PFC develops. Strengthening the brakes starts early. In a similar way, providing employees with adequate supervision, feedback, consequences, and reinforcement helps them perform better at work. Of course, too much supervision, or micromanagement, lessens productivity.

Here are five things you can do to increase your brakes, PFC, and impulse control.

1. Work on developing a great brain. Enhancing brain function makes everything in your life easier, including impulse control. Exercise, good nutrition, new learning, taking a multiple vitamin and fish oil supplement are all strategies to help overall brain health. Along the same lines, stop any behaviors such as excessive alcohol use, lack of sleep, smoking, excessive TV, or video games. Also, treat any conditions that negatively affect the PFC, such as ADHD, depression, or brain trauma.

2. Read your One-Page Miracle every day. Ask yourself repeatedly throughout the day if your behavior is getting you what you want. Do your words and deeds match your desires? This exercise helps develop clarity and decreases unwanted or useless behaviors. Remember, your One-Page Miracle needs to be your goals and desires, not someone else’s. As such, they are most likely to motivate you to stay on track toward your goals, but you must make them a part of your daily life. Your brain needs to see them every day. If you know that you want a kind, caring, loving relationship with your spouse, then even when you are stressed or irritated you are likely to act in ways that are helpful to your relationship.

3. Develop razor-sharp focus. Get rid of the things in your life that do not fit your goals. One of my friends, Timothy, an entertainment attorney who represents authors, complained that he did not have time for his family. He had a three-year-old daughter, Larissa, who adored her father but had recently been acting up. Her mother said she was having more tantrums during the day and appeared sullen. Larissa complained she wanted to see her daddy more, but he usually got home after she went to bed. Timothy struggled with guilt but also felt the need to build his business. There were too many things happening at work that he felt he could not let go. Knowing that I was a child psychiatrist, he wondered if she had ADHD or another behavior problem. After hearing the story, I thought that she might just be missing her daddy, like she said. I did the One-Page Miracle exercise with Timothy. Clearly, his wife and daughter were very important to him. Then I asked him to be aware of all his activities at work for a week. Keeping detailed notes on his activities each day, he could tell he was wasting time: he walked to the coffee shop twice a day for drinks, three or four times a week he went to lunch with friends, and he constantly took phone calls from colleagues who had questions about their businesses. In defining his work goals, I asked him what were the most important things for him to be doing at work. What were the tasks and activities that built and sustained his business? He wrote three things:

• Take great care of my current clients.

• Develop new clients.

• Spend 10 percent of my time in pro bono work.

I suggested that anything unrelated to these three goals he needed to let go. He understood the concept of total focus. He could bring his coffee to work (preferably decaf), he could limit lunch with friends to once a week, and he could allow his voice mail to screen calls from his nonpaying clients. Within a month, he was coming home earlier and spending more time with his wife and daughter. Larissa’s behavior dramatically improved. Spend time on the things that matter.

4. Know that saying no is okay. Too often, people feel anxious about saying no to someone. Many people, like me if I am not careful, are people pleasers. It bothers us when someone is upset with us, so we work hard to please others. We do not want to upset anyone. Somehow we believe that their unhappiness reflects badly on us. One concept that has helped me personally in this area I actually learned from my friend Timothy in the above story. He taught me to think in terms of “short-term pain versus long-term pain.” About the time I was helping him with Larissa, my oldest daughter asked me for another puppy. I had always had trouble saying no to her, but we had three other animals at home. When I discussed the situation with Timothy, he said, “Do you want short-term pain or long-term pain?” As he explained it, a puppy was potentially a fifteen-year decision, while saying no to Breanne was a disappointment that would likely last hours, days, or (worst-case scenario) weeks. It made so much sense, so the puppy found another home.

The principle of short-term pain versus long-term pain has helped me in many areas of my life from weight loss to relationships. When I look at the ice cream and feel hungry, I ask myself, “Is the hunger I’m feeling now (short-term pain) worth courting obesity, a condition that runs in my family (long-term pain)?” At work, if I need to fire an employee who is not working out, I often think short-term pain (the discomfort of letting someone go) versus long-term pain (the continuing hassles of having to deal with an ineffective employee). Whenever you find yourself in a quandary about what to do with an uncomfortable situation, just ask yourself, “Short-term versus long-term pain?”

5. Learn the phrase “I need to think about it. If I want to do it, I will get back to you.” So many of my patients have trouble saying no, and they impulsively say yes and end up taking on more than they can do, distracting them from their goals. Sometimes they take on so many things that they end up doing nothing. When you are not sure what to do, you do not necessarily have to tell people no. A better answer frequently is “I have to think about it.” Or “I need to talk to my board (or staff or spouse).” Give yourself time to make decisions about time. Then ask yourself whether the new task or request fits the goals you have for your life. Two quotes from Oprah Winfrey can be helpful to drive this point home.

One of the biggest lessons I’ve learned recently is that when you don’t know what to do, you should do nothing until you figure out what to do because a lot of times you feel like you are pressed against the wall, and you’ve got to make a decision. You never have to do anything. Don’t know what to do? Do nothing.

I didn’t want to say “No” because I didn’t want people to think I’m not nice. And that, to me, has been the greatest lesson of my life: to recognize that I am solely responsible for it, and not trying to please other people, and not living my life to please other people, but doing what my heart says all the time.

Use these five tips to gain more control over your PFC and impulses; developing total focus will get you much closer to your goals and overall happiness.