Whether you think you can or you think you can't, you're right. -Henry Ford

Introduction

Previously, the concept of using performance enhancing psychological skills (PEPS) to improve cognitive and technical skills during resuscitation has been introduced¹. This set of skills is represented by the acronym BTSF, which stands for breath, talk, see, and focus. These four elements can be remembered using the mnemonic “beat the stress fool.” The first of the skills, breathing, was discussed in Enhancing Performance in Resuscitation Part 3: Performance Enhancing Psychological Skills. This post will review the next skill, which involves implementing positive self-talk.

Talk: Engaging in a Dialogue Using Positive Self-Talk

Anytime a person thinks about something, they are, in a sense, having a conversation with themselves. The term “self-talk” refers to specifically to this internal dialogue, which includes both the content and structure of statements². The way in which one engages this internal dialogue in an emergency is very important. It plays a vital role in how individuals react to different situations³. In fact, some psychologists have referred to it as “the key to cognitive control”⁴ in high-stress situations.

Admittedly, the idea of talking to oneself may seem odd. However, we now understand that there is a powerful interplay between our thoughts, our feelings, and our actions. Self-talk is, in essence, part of an evidenced-based approach to treating psychiatric pathology: cognitive behavioral therapy (CBT). This modality has been exhaustively reviewed⁵. CBT has consistently demonstrated its value as a highly beneficial and cost effective solution to treating a number of conditions from anxiety⁶, to sleep disorders⁷, to schizophrenia resistant to certain medications⁸.

Anecdotally, self-talk has even been used to help people survive in life and death situations. On the evening of April 24, 2004, in Lansing, Michigan, Police Officer Robert Vargas was responding to a report of an intruder in someone’s house. Upon arrival at residence, Officer Vargas was ambushed by two armed gunmen. He was short in the left chest, forearm, back, and buttocks. Despite the dire nature of the situation and the severity of his wounds, he retreated from the residence and managed to successfully defend himself as the criminals pursued, and tried to kill him. One of the tools that helped Officer Vargas through the near-fatal encounter was positive self-talk: “I remember talking to myself, out loud, telling myself to ‘calm down. I’ve got to do this. I’ve got to stay alive’ I told myself that over and over. It was absolute terror”⁹.

In his book, Deep Survival, Laurence Gonzales discusses the science of human behavior and survival following catastrophic circumstances. Over the course of thirty-five years, he reviewed data in accident reports and interviews of survivors involved in a host of events including September 11^th, prisoner of war camps, and wilderness adventure mishaps. Gonzales discovered one of the key behaviors survivors display is developing a deep conviction that they will succeed and that they will live. Throughout the book he recounts a number of stories where this conviction was reinforced using positive self-talk. Steven Callahan survived 76 days sea in a life raft following a boating accident in the Atlantic Ocean. A key to his survival was his internal dialogue: “I’ve got to do the very best I can…the very best. I cannot shirk or procrastinate. I cannot withdraw…”¹⁰.

Self-Talk and Performance

Elite athletes use self-talk to improve their performance. Training athletes to be able feed themselves positive suggestions as part of an internal dialogue is a key aspect of sports psychology^11,12.

Research suggests self-talk can improve an individual’s perception that he or she can successfully perform a task, otherwise known as self-efficacy¹³. Hatzigeorgiadis et al performed a meta-analysis of 32 studies with 62 individual effect sizes based on self-talk interventions. Their results showed a significant positive effect of the self-talk interventions on athlete performance¹⁴. It is interesting to note that this effect was seen in both beginner and expert athletes. However, it seemed self-talk can be more valuable for novel situations or new applications of learned skills, as opposed those in which one was very familiar or the task was well-practiced. The authors summarize their findings succinctly in saying, “The mind guides action. If we succeed in regulating our thoughts, then this will help our behavior.”¹⁴

Psychologists have actually found that there are different kinds of positive self-talk. These include instructional, motivational, mood related and self-affirmative. Instructional self-talk, for example, may be statement like “maintain a tight grip” or “keep your knees bent.” Motivational self-talk, on the other hand, might consist of declarations as general as “I can do this.” Some authors suggest that these different types can effect different aspects of performance to different degrees; for example, instructional self-talk may improve fine motor technical skills slightly more than gross motor function. However, across the board, all seem to agree that effects on performance are beneficial^13,15,16,17. Perhaps most interesting is that self-talk may enhance skills acquisition in addition to performance¹⁷.

Tod, Hardy, and Oliver describe similar results in their systematic review. Their review included 47 studies that examined the effect of self-talk on 2,113 athletes. Most of the athletes were students (41%) with a mean age of 19.16 (SD = 4.88). A smaller number were actually professional or “elite level” athletes (22%). They analyzed study designs, types of self-talk, and context of the study among other variables. The results of their review indicated that self-talk significantly improved performance of both cognitive and technical skills. Furthermore, both types of self-talk (instructional and motivational) had significant beneficial effects¹⁸.

In terms of how to develop self-talk and what the content should be, Mikes developed six guidelines¹⁹:

1. Keep phrases short and specific
2. Use the first person and present tense
3. The phrases should be positive as opposed to negative
4. When you recite a phrase to yourself, say it with intention
5. Speak kindly to yourself
6. Repeat phrases often

While providing medical care to a critically ill or injured patient a provider must consciously and continuously feed themselves positive messages, words, or phrases of affirmation. Translating the evidence from other domains to resuscitation, one must tell himself or herself that they believe they have the responsibility to help their patient, they have the capability to address the clinical problem, and they will be successful. Also, one can develop instructional self-talk that focuses on important tips, tricks, or vital steps of a procedures.

Specific statements may be motivational like “this person needs my help to survive and I can do it” or “I know I can do this, I have done it before.” Alternatively, the self-talk could be instructional such as “focus on the angle of the needle angle going into the skin” or “advance OVER the rib into the pleural cavity.” One good example might be a mantra such as that suggested by Dr. Richard Levitan when trying to provide effective oxygenation to a patient: “Sit them up, jaw forward, oxygen through the nose.”²⁰ Providing statements of this nature is important to maintain confidence and a positive attitude during a stressful medical emergency situation.

Limitations

It is important to note some limitations of this concept. Its effectiveness is predicated on an established knowledge base and sound technical skills. Most of the research conducted in the literature was done with performers (astronauts, athletes, etc.) that already received a substantial amount of formal education and training. Thus, I would advocate that this psychological tool be used to augment conventional emergency medical training and education, certainly not replace it. I would also point out that there has not yet been a comprehensive examination of this skill in medicine. So, while it is inexpensive and has very little risk associated with its implementation, it needs to be formally investigated in the setting of resuscitation to establish the certainty of its value in emergency medicine.

When you engage in positive self-talk, you learn to think like an optimist.  As an optimist you will be able to visualize more options and solutions to your problems.  Your problem solving abilities will improve.  As an optimist you will be less prone to giving into defeat. -Richard Rosse, MD

References

1. Lauria, M. J., Rush, S., Weingart, S. D., Brooks, J., & Gallo, I. A. (2016). Potential role for psychological skills training in emergency medicine: Part 1 – Introduction and background. Emergency Medicine Australasia.
2. Hardy, L., Jones, G., & Gould, D. (1996). Understanding Psychological Preparation for Sport: Theory and Practice of Elite Performers (1 edition). Chichester ; New York:
3. Shapiro et al. “Effects of Mindfulness-Based Stress Reduction on Medical and Premedical Students.” J Behav Med 1998; 21(6): 581–599.
4. Bunker, L., Williams, M., & Zinsser, N. (1993). Cognitive techniques for improving performance and self-confidence, in J.M. Williams (ed.), Applied sport psychology: personal growth to peak performance, Mayfield, Mountain View, CA.
5. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17–31.
6. Kendall, P. C., Hudson, J. L., Gosch, E., Flannery-Schroeder, E., & Suveg, C. (2008). Cognitive-behavioral therapy for anxiety disordered youth: A randomized clinical trial evaluating child and family modalities. Journal of Consulting and Clinical Psychology, 76(2), 282–297.
7. Vitiello, M. V., Rybarczyk, B., Von Korff, M., & Stepanski, E. J. (2009). Cognitive behavioral therapy for insomnia improves sleep and decreases pain in older adults with co-morbid insomnia and osteoarthritis. J Clin Sleep Med, 5(4), 355-362.
8. Sensky T, Turkington D, Kingdon D, & et al. (2000). A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Archives of General Psychiatry, 57(2), 165–172.
9. Wilkson, S. (2005). Officer’s winning mindset and calming self-talk saved his life after terrifying ambush. Newsline. Calibre Press. Retrieved from http://www.policeone.com/officer-shootings/articles/1280849/
10. Gonzales, L. (2004). Deep Survival: Who Lives, Who Dies, and Why. W. W. Norton & Company.
11. Ungerleider, (2005). Mental Training for Peak Performance: Top Athletes Reveal the Mind Exercises They Use to Excel. Rodale.
12. Afremow, J. (2014). The Champion’s Mind: How Great Athletes Think, Train, and Thrive.
13. Hatzigeorgiadis, N. (2008). Investigating the functions of self-talk: The effects of motivational self-talk on self-efficacy and performance in young tennis players. Sport Psychologist, 22, 458-471.
14. Hatzigeorgiadis, , Zourbanos, N., Galanis, E., & Theodorakis, Y. (2011). Self-Talk and Sports Performance A Meta-Analysis. Perspectives on Psychological Science, 6(4), 348–356.
15. Hatzigeorgiadis, A., Thecodorakis, Y., & Zourbanos, (2004). Self-Talk in the Swimming Pool: The Effects of Self-Talk on Thought Content and Performance on Water-Polo Tasks. Journal of Applied Sport Psychology, 16(2), 138–150.
16. Hatzigeorgiadis, , Zourbanos, N., & Theodorakis, Y. (2007). The Moderating Effects of Self-Talk Content on Self-Talk Functions. Journal of Applied Sport Psychology, 19(2), 240–251.
17. Perkos, S., Theodorakis, Y., & Chroni, (2002). Enhancing performance and skill acquisition in novice basketball players with instructional self-talk. Sport Psychologist, 16(4), 368-383.
18. Tod, D., Hardy, J., & Oliver, E. (2011). Effects of self-talk: A systematic Journal of Sport and Exercise Psychology, 33(5), 666.
19. Mikes, J., & Meyer, (1991). Basketball Fundamentals: A Complete Mental Training Guide. Champaign, Ill: Human Kinetics Publishers.
20. Levitan, (2015, June 25). Extreme Airways. Social Media and Critical Care Conference. Lecture conducted from McCormick Place, Chicago, IL.

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Mike Lauria

Regular Contributor at EMCrit.org

Emergency Medicine Resident
University of New Mexico Health Sciences Center
Former US Air Force Pararescue and Critical Care/Flight Paramedic

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