“Take advantage of the enemy’s unreadiness, make your way by unexpected routes, and attack unguarded spots. ” -Sun Tzu, The Art of War

Question 8 from Tim Ferriss’ “17 Questions to Test the Impossible” in Tools of Titans again revisits the value of adopting an attack strategy that maximizes misdirection.

“8. What if I couldn’t pitch my product directly?” -Tim Ferriss, Tools of Titans

Tim had already approached the channel with the least traffic to get people’s ear. However he still wanted to use the media’s sounding board to get the word out. He realized that to get the mic he would have to use some misdirection. They weren’t interested in help him do promotion. Much less for free. Every other author had already tried that and failed. Media outlets probably trained their staff to reject any calls announcing “I think I have a book you’d love to talk about on your show.”

Instead Tim decided to try to get exposure for his book without pitching it. He came up with ideas to position himself in the public eye. Then that attention drove people to find his book. It is the same strategy as last week where subtlety allows the target to walk into the pitch on their own. By using misdirection, the target’s natural defenses aren’t engaged, the flank is left exposed, and victory is achieved.

I am very inspired when reading this part of the book and listening to the numerous podcasts that touch on it. As a psychotherapist it is part of my everyday approach. You could argue it is how therapy works (that and the privacy… and the relationship with a stranger who will never intentionally hurt you). As an athlete it is continually the space I find the most gains: what do I currently not realize I can do or think I can’t do? This is what has taken me from “I can’t run for two minutes without stopping” to a half Ironman and marathon. As a father it is where I see my kids find their greatest joy: the discovery of previously unknown ability. As a performance development consultant it is where I see clients earn my value tenfold: “I don’t know why I didn’t realize that.”

This strategy is straight out Sun Tzu’s The Art of War. I’ve mentioned this idea many times. We use it in psychotherapy where symbolism and metaphor speak to the subconscious around the conscious. I use it in Cogntive Behavioral Therapy by making your favorite hobby a medium for retraining your internal working model. It is the backbone of Behavior Modification with kids and pets.

The value here, I think is in continually trying to push your outer edge of comfort and familiarity. Asking yourself questions to explore ideas that aren’t intuitive. Really good questions that are provocative and awkward. “What if I had to pitch around my product” is such a question.

Mental Healthcare: the Stubborn Ox

My example of pitching around comes from my own journey as a mental healthcare reform advocate.

May was Mental Health Month. It was amazing to see so much conversation happening about mental healthcare. Both due to stigma and our own need to create confidentiality, mental healthcare usually has to lurk in the shadows. Instead we had a month of celebrities sharing their stories, articles talking about research and epidemiological data, and a few even people talking about treatment. One of my patients even decided to use his media platform to allow us to talk about our work together (should hit YouTube at the end of June).

All of this was great. However it was a minor step in the otherwise bleak path of mental healthcare reform. My path begins back in my residency training.

Coming out of medical school I had the false assumption of expertise and knowledge. Silly me for thinking that a degree in medicine and a license to practice would confer any sense of being. Instead it was 5 years of being marginal at a thing while you watched others do that thing better than marginal. I was lucky to land at a program for my adult training that routinely turned out very high quality psychiatrists. Our hospital-based work and our clinic-based work were each run by guys that were extremely good at their craft. Not surprisingly, one had actually trained the other himself. When I went to my child fellowship I again ran into a psychiatrist who did the job in a way that made it look more like art than work. These experiences left me with one impression: the people at the top of my field know what they are doing.

Then I finished training and moved to California. Here I found a new breed of “knowing what they were doing”. It wasn’t clinical skills, though I’m told each has a masterclass level at that too. It was advocacy.

For years I had struggled with my identity as a psychiatrist. From jails to inpatient units, I consistently worked at places where I was exposed to psychiatrists who did not approach care the way my intuition thought best. However the hierarchical nature of medicine trained me to think that  I am young so I must be wrong. The status quo is always right. I was identified in both adult residency and child fellowship for being “a problem” because I talked about trying to do things better. The verdict was always “what makes you think you could ever know what is better than an institution that has been doing things this way for years?”

In my California group of collaborators I found people willing to say to the rest of our field “we can do better.” It felt great. I’d found my place. I surrounded myself with providers who valued time with their patients, building relationships, and working through therapy. I found people also suspicious of the secret relationship between doctors and pharmaceutical companies that ultimately brings harm to patients. Together we talked about our shared experiences of seeing fantastic results in our patients and doing so via high-quality psychotherapy. It felt like discovering pencilllin. EVERYONE NEEDED TO KNOW THIS!

Together our group took this message back to the people at the top of our field. We were elected advocates representing Northern California child psychiatrists. Twice a year we travelled to the national  advocacy meeting to bring our message. Then it happened. The same thing that always happened when I tried to ask doctors to consider doing things a different way. We were rejected.

It wasn’t your average rejection either. Exit polls from the meeting called our message against pharmaceutical bias and fraud in medicine “the least valuable part of the meeting.” We had esteemed members of our field stand up to rail us for monopolizing the time with this issue every 6 months. We were told by a very high up elected official that “doctors have better uses of their time” than to pursue what we are doing. We had a room full of psychiatrists cheering when someone stood up to ask us to not bring this issue to the table again.

It was heartbreaking. I don’t use that word lightly. We were children who had made breakfast for our parents on their birthday and they told us they weren’t hungry. Such was the impact that we didn’t even take the microphone to fight back. We just sat. Gobsmacked. It wasn’t even the pain of the rejection. It was the saddness that realizing our colleagues were so far away from fixing this problem. We would have to prove to them there was a problem before we could even problem solve it.

In psychology we call this the pre-contemplative state of change. It’s the alcoholic who doesn’t think they have a drinking problem. You are trying to prove to them the sky is blue but they don’t even believe there is a sky. They are too busy looking at the ground.

I had been transported back to my training. I thought a thing and was told I was wrong not on the merit of the argument but on the a static value that I could not be right. It was about this time that I remembered something that gave me clarity. A sentinel moment from my training. The last day.

My fellow trainees and I were sitting around a table having lunch on the final day of our fellowship. As doctors do at this stage, we were all freaking out about the prospect of being on our own in a week. A simple question had come to mind- how often do we need to check vital signs in our outpatient practices? We each agreed on an answer- every time. Then someone offered a counterpoint. One of the docs she worked for didn’t do them regularly. “Oh that’s malpractice.” Then someone asked a great question: “where did we come up with our idea of checking every appointment?”  “Every time” was our clinical policy in the program. “Where did they get that?” “Don’t know.”

We were left with no final answer. All of our cognitions of when to check vitals were based on a supervisor telling us what they thought. We accepted it. They knew how to do a thing better than us. They must be right.

Being the rabble rouser I am I decided to hit the internet for answers. In 5 minutes I had the practice guidelines for Pharmacologic Management of Psychiatric Disorders in the Pediatric Population. Guess what happened. Our teaching had been wrong.  WAY wrong. Our clinic policy. Also wrong. It likely existed to appease an insurance company, not to represent the standard of care. Santa Claus didn’t exist.

It was both exciting and tragic. The tragedy being that on the last day of training we realized a flaw in our education. In two years we hadn’t once seen this document I found on the internet in 5 minutes. Why? What else were we missing? On the other hand, the excitement was the feeling that maybe I could allow myself to think intuitively again. That is until I fast forward 2 more years back to our rejected advocacy efforts.

Pitching Around Mental Healthcare Refoem

Having now experienced three iterations of unsuccessfully trying to talk change with a bunch of psychiatrists (the irony is stifling), I needed to return to my Sun Tzu. And my Tim Ferriss. This rock wasn’t going to move. I needed to stop trying. I needed a different strategy.

“What if I had to pitch around my product?” How would I flank mental healthcare reform? Surprise it. Create change without ever asking permission or it knowing it had decided to change. I’d previously been trying to do an intervention on an alcoholic who argued  “I just like to have a little something to relax”. That was my mistake. My miscalculation. My learning.

I found my flanking technique.

What was the goal of my attack on mental healthcare reform?

Better patient care. Improved median wellness for humans. The development of mental healthcare as profession highly skilled people fought to achieve.

I realized that while psychiatry does the best job helping people with severe illness, we do a crap job for everyone else. What other industries offer people a path to wellness? That answer was easy: fitness, art, sport, execution of one’s job, and many others. In fact, I decided that every industry was bringing someone somewhere a “best in life” experience. Maybe that could be a way to use my skill to move the needle on wellness. What if I can use those mediums to help people?

Soon after this experience I launched Optimim Performance Consulting. A few months later I became a consultant for Equinox Fitness’ personal training programs in Northern California. I’d left medicine and found people interested in change and doing things differently. Ironically it is requiring me to not function as a psychiatrist. No evalutions. No therapy.  All strategy and practice.

Here I can achieve exponential gains. The managers I work with each have teams of 5-10 trainers. Those trainers each have dozens of clients. If our work together can help people achieve goals even 1% more efficiently the net gain for society is tremendous. That’s more impact than I can have as a physician any day. That is if you buy that achieving goals is what is best in life for humans.

In thinking about helping people in this indirect manner so many options open up. As a consultant I can help game developers consider ways to promote wellness in their users thus creating a more sustainable audience. I can talk to a start-up about how to create a culture shift toward Positive Psychology and a Growth Mindset. I can work with athletes, artists, and performers to improve their craft and maybe achieve improved mental wellness as a biproduct. It’s perfect.

Summary

I’ve sold hard on the idea that best thing to come to our lives is probably hiding in a recess of unconsciousness. This certainly pertains to anything we wish were different. Rather than keep pushing on a locked front door, we should come around the side and see if we can crawl through a window. From Sun Tzu to Tim Ferriss, if you ask yourself to find indirect approaches to success you will unlock greatness. It is evidenced in Tim’s book launch and my experience trying to improve human wellness through non-medical consulting. Intentional change is one of the most valuable experiences in human life. It can happen predictably by engaging unique systems like this one.

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