The Most Important Lesson

We all have ideas that set the foundation of our thinking and help us navigate our way through life. This is true whether we are navigating our jobs, our family, or a painful experience. Yet, most of the time, we are not even aware of these core ideas we are using to make our decisions. Even if we are aware and can articulate our thinking, we rarely know the origins of how the idea emerged in our life. We have inherited most of these ideas from our families, friends, and our tribes of association. Today I want to talk about one of these ideas my patients and I have found helpful in navigating life's challenges. The idea is referred to as the Dichotomy of Control (DOC), and it has origins in Stoic philosophy with Epictetus right at the beginning of the Enchiridion stated here:

"Some things in life are within our power, while others are not. Within our power are opinions, motivation, desire, aversion, and, in a word, whatever is of our own doing; not within our power are our body, our property, reputation, office, and, in a word, whatever is not of our own doing."

If we take a deeper look at this, what Epictetus is saying is that we are in charge of our deliberate judgments, our opinions and values, and our decisions to act or not to act. Stated simply, we have control over what we decide upon after deliberation and reflection. That's it—nothing else. Since most of our thoughts occur automatically, this means that the majority of our mental life is not in our control. And obviously, all the externals, including health, the pain we experience, wealth, reputation, and so forth. While we can influence these externals, they ultimately depend on a combination of things, including other people's actions and the environmental circumstances. While the limitations of what is actually in our control can be hard to swallow, this distinction can have profound effects in helping direct our attention and efforts if we accept it.

We want to use the DOC to direct our attention and actions to what we can control in our lives. However, if we truly make this wisdom actionable, the flip side of this coin is that we need to accept the things outside of our control. The struggle to control that which is outside of our control causes us the most suffering. While almost always challenging, acceptance is often the most productive step to redirect our efforts and manage ourselves productively.

A common metaphor used to understand this idea is to think of an archer shooting an arrow. An archer aims at his target, pulls tension on the bow, and then decides the right moment to release it. These are the things that are within the archer's control. After the shot has been released, the target could move, a gust of wind could blow the arrow off course, or the arrow could be deflected and hit an unintended target. These are things that could happen that are outside the archer's control. To become better at archery, the archer must focus on refining what is in his control. He gets better at the process of aiming, and his timing for when to release the shot improves with practice. It is essential to understand, though, that even the best archer will have trouble hitting a moving target on a windy day. When helping people in persistent pain, this is often our starting point. Persistent pain is a moving target, and most of our lives occasionally experience some unexpected gusts of wind.

In the clinic, I've observed that much of people's suffering comes from their desire to control pain or their rate of progress, but unfortunately, these are precisely the types of things that fall outside our control. In the archery analogy, pain is a target that is constantly on the move. This perspective usually has other adjacent ideas attached to it, including searching for the "right" treatment to fix the problem. The person with this perspective usually "zooms in" their attentional focus on the details of their experience. The DOC tells us that the best thing to do in these circumstances is to accept our experience for what it is, especially when it's unpleasant, and to direct our attention to what we can control.

When I see patients embrace this idea, their pain becomes information that they can use to make better decisions. Their pain experience becomes something useful that is part of their life. They accept its presence and stop constantly trying to escape it. Instead of zooming in, they zoom out on their life. They find clarity around their values and take actions to engage in activities meaningful to them.

Let's take this idea and apply it to a clinical example. Imagine you are suffering from back pain; now what is and what is not in your control? Escaping the pain is not in your control. While there might be something you can do to influence its immediate intensity, whether or not the pain presence continues or subsides is not in our control. What is in our control is how we use the pain to make decisions. We can decide to go for a walk or rest on the couch. We can choose to take a week and see if it gets better on its own, or we can seek immediate medical attention. We can decide what information is going to be best to pursue. We can look at our lives and think about what's changed recently and if those things could be affecting our pain. We can think about what's weighing on us and if our overall lifestyle is healthy. Or we can use doctor google and diagnose ourselves with terminal cancer. Generally speaking, taking small actions and reflecting on our lives more broadly tends to illuminate the path to managing pain ourselves.

While the idea behind the DOC is simple, putting the concept into practice can be tricky. First of all, it takes practice to distinguish things in our control from things that are not in our control. When starting to use this idea in your life, it can sometimes be helpful to write down the things you want and then ask yourself what aspects of the process in trying to achieve that goal are within your control and which are not. Writing things down will help you sharpen what to pay attention to and what actions you can take or not take to help you reach your goals.

Questions? Contact us!