Book Review-The Secret Lives of Adults: Your Seven Key Relationships – and how to make them work

Who are we really? Are we the person we are when we’re with friends? Or is it that we’re the person we are with family? Or perhaps we’re really expressing our true nature when we’re by ourselves. In The Secret Lives of Adults: Your Seven Key Relationships – and how to make them work, Allison Keating explores the different aspects of our identity.

Seven Relationships

Keating believes we have seven key relationships:

  1. Me, Myself, and I
  2. Mum (Mom) & Dad
  3. Siblings
  4. Romance
  5. Parenthood
  6. Friends
  7. Work

These relationships are how we express ourselves. Fundamental to this is an understanding of how to bring our whole selves to each of these relationships and how to fit these images of ourselves together. I’ve spoken a few times about the need for and power of an integrated self-image. (For just some examples, see Braving the Wilderness, Happiness, The Trauma of Everyday Life, Schools without Failure, Compelled to Control, and Beyond Boundaries.)

Being an Adult

Whatever image we see for ourselves, it should be an adult. Richo speaks in How to Be an Adult in Relationships about what it’s like for us to be the most authentic human that we can be. Keating takes a different approach: instead of focusing on the things we need to give ourselves and others, she seeks to help us better understand ourselves.

We’ve this unconscious assumption that adults must have life all figured out. After all, as a child, we thought our parents were all-knowing and really had it sorted. At least, we felt like this until we became teenagers and suddenly decided we knew more about life than they did – only to return to our beliefs that our parents knew everything when we hit our twenties.

The problem is that this is a false belief. Being an adult means you’re willing to confront the places you don’t have figured out, but few adults I know feel like they’ve got it all figured out. Instead, most of the folks I know, who are brave enough to be honest, know that we’re all struggling to do our best in a world that keeps changing. We hope that our awareness of the world continues to grow.

Relationships Today

As Sherry Turkle explains in Alone Together, we’ve got technology that connects us nearly every moment of every day, but at the same time we’re more alone than we have ever been. We have fewer confidants and fewer real friends, even as the number of our Facebook friends blossoms. Friends are an emotional buffer that allow us to weather the storms of life. Without them, we feel buffeted by the minor challenges of day-to-day life and poorly equipped for all that being an adult means.

Our friends today are less likely to know about the deep, emotional scars we carry with us since childhood and the embarrassment of our past. As a result, the friends we do have are poorly equipped to know when they need to step up and support us.

Reflection

The pace of progress continues to increase. We’re producing more food than ever before. We can meet our own needs with fewer hours of work than ever in the history of humanity, but we’re also working more hours and harder than even a few years ago. The competition bug has caught us. Social media has turned up the volume on the age-old problem of “keeping up with the Jones’.” We get caught on the hamster wheel of work and keeping up, and we barely realize we’re doing it.

Gone are the days “on Walden Pond,” where a deep thinker could sit and stare at the water and peer into their own souls. It’s easier for us to login and find out what someone else is thinking (or saying they’re thinking) than it is to connect with ourselves and what we truly think, feel, believe, and fear.

The tyranny of this is that it binds us to the hurts of our past. No one seems to know about the hurts. Not our friends. And, buried under layers of denial, not even us. We react to others based on events that we no longer remember.

Knowing and Not Knowing

A Johari window is a simple, two-by-two grid of knowing and not knowing both ourselves and others. It creates spaces where we know things about ourselves that others don’t know, things that both we and others know, what others know but we don’t, and, finally, things that neither others nor we know about ourselves. It seems that, instead of peering into the space where no one knows, we’re more interested in staring at the spot where others know things about us that we don’t know.

We’ve become obsessed with “what do they really think about me?” In an age of political correctness and ethical and moral weakness, we must wonder: is what someone telling me what they really feel? Too often the answer is no, and we know it. But we also know that getting to the real answer may not be possible because of the fears they carry inside of themselves. (See The Fearless Organization for more about fear and its impacts.)

Awareness

Sometimes, the knowledge that you gain about yourself addresses the limitation – and sometimes it doesn’t. Knowing you have the flu doesn’t stop you from having it. It can, however, inform what you do and how you change your behaviors so that you can get better. With the flu, you may choose to get more rest, but you’ll still have a few days before your body has a chance to recover.

On the other hand, knowing that you are sabotaging your success by a simple behavior, you can stop the behavior and get more success. The amount of action (or inaction) required is trivial compared to the challenge of awareness.

The journey to understand ourselves is filled with both kinds of awareness. There’s the kind that makes the problem evaporate – and the kind that exposes the long path that we have to recovery.

Attachment

Much of the hurt we experience and react to is said to come from our attachment style. John Bowlby and Mary Ainsworth described the attachment styles as: secure, ambivalent, avoidant, and disorganized. (For more see Daring to Trust.) Of these, only secure attachment was considered to be non-afflictive. That is, people with secure attachment styles have fewer places of harm and are therefore supposed to be less reactive to environmental stressors.

In practical terms, your attachment style isn’t fixed. (See Mindset.) You can heal old wounds by recognizing them and working through them. In effect, we walk towards the pain that we felt, and we resolve it rather than ignoring it. Ignoring the pains we feel leaves us vulnerable to someone else triggering the emotional landmines that we’ve buried. (See Step, Step, Click for more.)

Unconscious Time Travel

It seems that our unconscious doesn’t notice the passing of time. This was hinted at in the movie A Beautiful Mind. (See Incognito for more context.) The point the movie made was that Nash’s friend and the little child that he saw never aged. They never changed as he aged. It’s almost like they were frozen in time. This is an interesting curiosity that could be relegated to a value for dream interpretation until you consider how we respond to hurts.

Our response to hurts is quick and automatic (see Thinking, Fast and Slow for more on how this happens). In that response is no sense of the time that has gone by – or even, to some extent, how the situation has changed. We’re still that frightened little boy or girl on the inside. It’s that frightened boy or girl that’s lashing out. Until and unless we can quiet the pain of that spot inside ourselves and learn to be okay, we’ll never be able to stop the outbursts. Whether we were injured ten minutes ago or ten years, we’ll still respond to similar situations – until we address the core.

Unlovable

Perhaps our greatest fear lies beneath the surface. The fear is that we’ll be or become unlovable. Some memory back before our brains were fully formed warns us that we’re dependent upon others. We hear every criticism as a hint that this fear of being unlovable may be true. Deep inside, we can’t stop the nagging feeling that we may be unlovable and therefore ultimately vulnerable again.

The nagging feeling can be pushed back. It can be kept from surfacing too frequently, though everyone seems to have it surface now and again.

Constructive Arguing

Some people are taught by their environment that they must always be agreeable. Perhaps their family system is predicated on the need for tranquility at all costs. Instead of having healthy disagreements and constructive arguments, hurt feelings are buried until the day that they boil over. Everyone else is surprised, half at the content of the explosion and half that the family member couldn’t keep it together.

In a system where conflict is bad – rather than constructive – it’s hard to make it ok. In other environments, healthy means sharing feelings without being hurtful and arguing about the perspectives and the values but not about the worthiness of the people. As we learn to be better adults, we learn that, to be ourselves, we must be willing to engage in constructive arguing – and we need to learn how to do that well. (Here, John Gottman’s The Science of Trust is great.)

The Cult of Easy

While the need for tranquility may be isolated to some families and some environments, it seems like there is the perspective that things should always be easy. We shouldn’t have to pour our hearts and souls into things, it should just come naturally, like the YouTube star who seems to effortlessly makes millions.

The truth is “Tenacity, hard work and persistence, especially in the face of adversity, are how you succeed.” As we learn to be adults, we learn that adulting isn’t easy. It’s not easy to face the fifth or fiftieth rejection – or the five-hundredth. It’s not easy to slave over something for years or decades in obscurity believing that something will turn any day now. However, it is how success is won, at least for most of us. (See Grit for more.)

Accepting Your Feelings and Frustrations

In the end, being an adult means accepting your feelings – good and bad. That includes the joy and the frustrations. You can’t side-step or ignore your feelings, because they will eventually come out whether you want them to or not.

Feelings are a part of The Secret Life of Adults – and just like the book, they’re worth discovering.

Book Review-Transformational Security Awareness: What Neuroscientists, Storytellers, and Marketers can Teach Us About Driving Secure Behaviors

The first highlight I have for the book is “Just because I’m aware doesn’t mean that I care.” It’s a truth that we first get exposed to around the age of three, when our theory of mind begins to accept that others think differently than we do – or at least they have different information. However, it’s a key challenge to remember when it comes to how to create a security awareness program that works, as Perry Carpenter explains in Transformational Security Awareness: What Neuroscientists, Storytellers, and Marketers can Teach Us About Driving Secure Behaviors.

One of the things that I do from time to time is help some of my friends who work in information security. I’ll spend a few months helping them with some aspect of their systems or their programs, and then I’ll go do other things again. I’ve found that it’s hard for me to personally stay in information security for long, because I don’t want to remain vigilant for threats all the time.

Social Engineering

What’s the most vulnerable part of any security program? The answer is always humans. We can plan the best systems, implement the best hardware and the best software, only to find that a human is responsible for letting people through the back door. How many physical security plans have been thwarted by someone propping open a door, letting someone “official-looking” into the building, or failing to make sure the door is latched behind them? I can say that I’ve walked into buildings that I should have been escorted through simply by grabbing a door before it latched.

I learned about social engineering years ago through Social Engineering. Most of what people would consider social engineering, I’d put in the consultant’s essential toolkit for getting things done without authority. It’s about ways of getting folks to break – or ignore – the rules, and it works.

The Gaps

There are two critical gaps in security awareness that we’re always trying to solve. The first is the gap between knowledge and intention. We all know that we should exercise, get proper sleep, hydrate, and eat healthy. That’s our knowledge. However, few of us would say that it is our intention to do all these things. That is the first gap between what we know and what we intend. It’s further than the distance between knowing and caring – it’s more than caring, it’s deciding that we want to take action.

They say the road to hell is paved with good intentions. Note that it’s not good actions – it’s good intentions. Even if we’ve decided we want to take action towards something, will we actually do it? Many have had great intentions and set their New Year’s resolutions only to decide that their resolution was too much work – some before they even start.

With the two gaps, there’s often a huge gulf between what you’ve taught people and how they actually behave. Some of that may be due to the forgetting curve (that they’ve forgotten since they were taught), but this doesn’t account for the wide discrepancies.

Speaking of Security

When we’re speaking about security, we need to make sure that the messages are personal, emotional, and relevant. I often explain that everyone listens to one radio station – WIII-FM or “What is in it for me?” The result is that if the message isn’t tuned to them and their personal circumstances, it may not be heard.

One of the common challenges when working with messaging in business is that people assume the messages must be dry and devoid of any emotion. Organizations are starting to realize that you have to accept emotions in the workplace if you want a high-performance and high-functioning team. However, the idea that emotions are a useful tool hasn’t made its way to the folks who teach communications at most organization.

Finally, messages about security must be relevant. There’s a signal to noise ratio that people use for determining how much they’re going to pay attention to. The more irrelevant things they experience from you and your team, the less that they’ll pay attention to your messages. For the sustainability of the program, they must perceive things to be relevant to them when you communicate.

Events vs. Environment

Carpenter speaks about security awareness needing to be more than an event. Instead of the annual security awareness training, effective security awareness is continuous. It is, perhaps, punctuated by big events, but, overall, it’s an environment where everyone is reminded about the relevance of their need to be vigilant against threats. When Carpenter describes the difference between what most people do and what is effective, he uses the word “campaign.” However, even campaigns have ends. I prefer to think about how it’s a part of the continuous addition of information into the environment to reinforce the learning.

Lazy Brains

Carpenter points out that we use lots and lots of mental shortcuts for the work we do on a daily basis. Our brains are calorie hogs. They consume 20-30% of the glucose (or sugar, our bodies’ fuel) but represent only about 2-3% of our body mass. (See The Tell-Tale Brain for more.) Because our brains are lazy, we use lots of heuristics (shortcuts) that hackers exploit to get us to do things that we wouldn’t do if we fully considered them.

Motivation

Carpenter uses the Fogg Behavior Model – which basically states that you need enough motivation and ability to respond to a prompt. The greater the ability, the less motivation is required for a prompt to be effective. We all prompt people to do something. We ask them to do something, and they decide whether they will do it based on their motivation and their ability. This reminds me about how The Psychology of Hope speaks about hope being composed of two pieces – willpower (motivation) and waypower (ability). Kurt Lewin said that our behavior is a function of both person and environment – what we bring with us and the pressures or motivators of the environment. (See Leading Successful Change, Moral Disengagement, and many more for Lewin’s equation.)

The Fogg model does have the benefit of clarity around a triggering event. A latent ability and a motivation will not activate without some sort of triggering event – that could be an internal thought or an external prompt, but something has to start the reaction. Think of it this way: gasoline has a great deal of potential – but that potential is only activated with some sort of a spark.

Facts and Frames

Carpenter aptly points out that one of the biases we all suffer from is that we’ll tend to ignore those facts that don’t fit our frame of thinking. When facts and frames meet, frames will almost always win. Our brains love consistency and abhor inconsistency. When something comes across our awareness, and it doesn’t fit our frame, we seek to find a consistent answer. Given the investment in our frame, the fact is often quickly jettisoned.

The frame further shapes the way we process our environment and how we’re motivated. It’s like walking around with rose-colored – or green-tinted – glasses. We see the world through those glasses – whether we want to or not.

Working with Users

Users may feel like a frustration from time to time, but the reality is that, without them, there would be no need for security or security awareness. We can think that they should know better, that they should keep separate passwords for separate sites and systems, but the reality is we’ve exceeded the reasonable capacity for our users to do the behaviors we think they should do. A typical user might have 100 sites they use in varying degrees of frequency. There’s no practical way to remember that many passwords without the aid of a system.

I don’t know any corporate infrastructure team that doesn’t have some sort of password management system to manage their passwords. Why would we deny users the same tools if we know, as professionals, we can’t manage passwords without a tool?

In our work with our users – I like to call them business clients – we must work with their limitations, or we’ll be constantly disappointed in them and in the success of our security awareness programs.

Emotions

It’s not supposed to be about emotions. It’s black and white, on and off, true or false. Or at least that’s what we want to believe. As Daniel Kahneman aptly points out in Thinking, Fast and Slow, our emotional, automatic, first response can lie to our thoughtful, rational brain – without us even realizing it. It’s this lying that we do to ourselves that malicious individuals can take advantage of, and it all comes down to emotions.

So, don’t get angry when users let the next malware into the organization; read Transformational Security Awareness so it doesn’t happen again.

Book Review-Burnout to Breakthrough: Motivating Employees with Leadership Tools That Work

Everyone has a backstory. You do. I do. Every author I meet does. Everyone I read has some sort of a backstory that has led them to where they are today. That’s certainly true of Ina Catrinescu. She relates part of her childhood from the former Soviet Union in Burnout to Breakthrough: Motivating Employees with Leadership Tools That Work. She has a unique perspective on the “chains” that bind us. Having moved from the socialist world to the capitalist world, she’s seen firsthand how both worlds have the capacity to demoralize and demotivate people. One was enslaved to an immutable dogma, and the other is tethered to a rat race.

Overwork

Around my house, the family is quite fond of saying that, if anything can be done, I’ll overdo it. I believe in excellence and have been known to take on some crazy projects. (Like the solar powered mini-barn.) However, I’ve got absolutely nothing on the Japanese, who created a whole word that means “overwork to death:” karōshi. It’s more than a high suicide rate. It’s literally being so encompassed in their work that they’ll keel over at their desks. They’ll work until they simply can’t work any longer.

Not to be outdone, the former Soviet Union taught kids songs that basically translated to, “Your only purpose in life is to work your fingers to the bone, and you better do so thoroughly because the whole country is watching!” While this may not rise to the death toll of karōshi, it’s still a powerful push towards overwork.

In America, we’re subject to our own factors. Our protestant work ethic has us believing that we need to work not to live but rather work to achieve. Achievement, for many, is measured in the cars you drive, the neighborhood you’re in, and the clothes you wear. We work so we can get more things that prove to others that we’re working. As more people work and can afford these things, we must find ways to differentiate ourselves and demonstrate that we work hard.

Productivity has improved 97.5% since 1960, but that hasn’t meant that we work fewer hours. In truth, we’re working as many or more hours today than we ever have. Greater productivity isn’t reducing the number of hours we’re working.

Minimum Income

Communism was a grand experiment. At least in the case of the Soviet Union, it didn’t work out. Another experiment was done in Canada that did work out – until it was stopped. What would happen if you offered people money every month with no strings attached? Would the recipients become lazy and do-nothing, or would they use the money to get back up on their feet? The experiment in Dauphin, Manitoba, Canada did just that. Money was provided to low-income residents with no strings attached. They could continue to receive it for as long as they needed it.

The results seemed positive even though the program was stopped. It seemed like the results were better health, but as of now, the program hasn’t been tried on a broader scale.

Prosperity not Profit

Most organizations measure their results with a balance sheet. It’s net income that matters. However, much like gross domestic product doesn’t capture the full picture of the good we’re doing, profit isn’t the full measure of the organization. (See The Hope Circuit for Gross Domestic Happiness.) Red Goldfish explains how looking at the good you do in the world may be good for your bottom line. Reinventing Organizations focuses on how increasing the level of consciousness in the organization can be an important part of bringing more joy to the individual, the organization, and the world.

More people are trying to figure out how to run their lives with the new bottom line. Instead of it being all about money, it’s about impact. While not everyone is trying to find a way to make the world better, more people are considering it. Given that the roots of burnout exist in the world of caring professions, in which professionals try to “change the world,” it’s no surprise that this idealism, while beneficial to the world, can cause challenges to the psyche of the individual.

Finding Meaning

Finding your “why” is a challenging – and evolving – thing for everyone. (See Simon Sinek’s Start with Why for more.) Despite the challenge, without a sense of purpose, you’re likely to find yourself adrift without a clear sense of what you expect to get done and what you need to be focused on.

Privilege of the Platform

Years ago at an NSA annual event, I heard a comment that has stuck with me. “The privilege of the platform” resonated, because, despite the fact that so many people fear public speaking, it’s still an honor to be asked to share what you know with so many people. The platform isn’t a right, an obligation, a duty, or a task to be done. It’s a privilege. Similarly, management can be seen as a burden or a great opportunity. Robert Greenleaf in Servant Leadership speaks about how leaders serve those that they lead.

When we speak about burnout, we find that we speak about the difference between “having to” and “getting to” do something. It’s obviously a mindset shift, but it’s one that makes a big difference.

Values are not Virtues

Everyone has values. Whether we can articulate them or not, everyone has values that they hold. However, not all these values are virtues. Just because you value something doesn’t make it virtuous. It seems that too many people believe their values are universal values that everyone holds rather than recognizing that we each have our own values and motivators. (See The Righteous Mind and Who Am I? for different ways of learning what values we hold and what motivates us.)

We must accept the reality that others hold different values than we do.

What About Burnout?

There is a lot of good information in Burnout to Breakthrough, but, in the end, I found that I struggled to find the tie-in to burnout. While you may get a lot of good information, I’m not sure how it will help you avoid or prevent burnout.

Book Review-The Burnout Solution: 12 weeks to a calmer you

The recognition that burnout is more than a “job thing” and can impact any area of your life was one of the reasons why the book The Burnout Solution: 12 weeks to a calmer you was interesting. As with most burnout books I’ve read, there’s a lot to agree with – and enough to disagree with.

The Role of Stress

Many people – particularly those who have been led astray by some of the academic literature – like to say that burnout is caused by stress. The problem is that’s an oversimplification of what’s really going on. To understand, we must understand the basics of stress, how we appraise stressors, and, ultimately, the root cause of burnout.

When it comes to stress, I always start with Why Zebras Don’t get Ulcers. I start there because it’s the most complete coverage of stress that I’ve found. It took me three blog posts to do a review of it because the information was that powerful. The short version of stress is that it’s a “payday” loan. It’s a high interest loan against the future, so that you can survive today. When we feel stressed, our body makes choices that work for the short term at the expense of our long-term productivity, energy, and efficacy. One of the things in Why Zebras Don’t Get Ulcers that contradicts The Burnout Solution is that the impact of stress is a reduction in immune system response – not an increase. Research consistently shows that the introduction of steroids (including the cortisol released during stress) makes people more susceptible to infection, not less.

The tricky part about stress is that it’s almost always generated internally. Certainly, there are objective stressors in the environment, but they don’t convert to stress unless our appraisal of the stressor is that we’ll be overly harmed or overwhelmed by it. (See Emotion and Adaptation for more on how we appraise our emotions – including fear, which causes stress.) When we believe that we have all the resources and support necessary to overcome the stressor without any real risk, a stressor doesn’t convert to a stress. Thus, stress is something we generate internally.

The root of burnout is our belief that we can’t be effective. If we can’t manage our stressors, we can’t make progress towards our goals, and we’ll perceive ourselves to be in burnout. Secondarily, the impact of stress is short-term gain at the expense of long-term efficacy, which further deepens the perception that you’re not effective. At some level, stress is coincident with burnout, because the belief that you can’t navigate or overcome the stressors exists in both. However, at another level, stress is just a sidekick, not a cause.

Self-Imposed Demands

When Terri and I talk about the bathtub model in Extinguish Burnout, we explain that demands have a valve, and we can control the degree to which we accept them – even the degree to which we generate them ourselves. It’s one thing to learn to say no to others. It’s another thing to say no to the “shoulds” and “aughts” that happen inside your head.

More than anything, understanding how we view our demands and learning to change our perspective can allow us to hold onto our personal agency.

Impatience is a Reaction, Patience is a Response

When it comes to finding more calm, learning to respond and not react is important. We’re wired with two systems (to use Kahneman’s language from Thinking, Fast and Slow). The first system is quick and instinctual but often devoid of consideration of the long-term consequences of actions. The second system is more contemplative and is a response instead of a reaction.

When we tune our ability to change our appraisal of events, and we can consider them in a larger context, we’re able to be calmer – and, in the perspective of The Burnout Solution, we’re able to prevent burnout. I believe finding calm is an important goal. I even believe that reducing stress will reduce the degree of burnout you’re feeling, but I’m not convinced that solving stress alone will do it. However, read The Burnout Solution and make your own decision.

Conflict: It’s Not Personal

Conflict is easy to get wrapped up in. When someone else sees the world differently than we do, it’s natural that our sense of right and wrong is challenged and, as a result, we’d become defensive – and ultimately lash out. The problem is the first conflict isn’t personal. It’s just a difference in perspective or values. It’s once someone starts attacking the other person that conflicts become personal – and they become harder to reach positive outcomes.

Idea not Person

In a conflict, there are different ideas to consider about how to move forward. One person believes the best answer is one thing, and the other party believes something different is the answer. It’s appropriate in a conflict to identify both the strengths and weaknesses in the opposite proposal or proposals. Conflict is valuable, because it has the capacity to help us see the things we might otherwise overlook.

Pointing out the limitations of an idea is perfectly reasonable. Of course, it helps to have communication skills that allow you to point them out in a way that is respectful, but regardless of the delivery of the message or how it’s taken, it’s important to stay on the idea.

Conflicts often wander into the territory of labeling the other party rather than sticking with the idea. We can explain that we don’t understand an idea but get ourselves into trouble when we start saying the purveyor of that idea is stupid, an idiot, or some other less-than-charitable name. We’ve moved from discussing an idea and its relative merits to attacking a person’s identity.

The Ego and Its Defenses

A person’s identity is sacrosanct. Most of the time, it’s difficult for the person themselves to change it. Someone coming from the outside saying the way they think of themselves is wrong isn’t going to be well received. This is doubly true if you’re trying to negatively impact their identity and self-image. The ego, which is responsible for our perception of our identity, is well defended. There are a variety of techniques that the ego can use to defend itself against an unwanted change in self-perception.

This difficulty in changing identity is why when people are given negative feedback about who they are – rather than what they did – they almost universally respond negatively. We’re surprised by the person that takes negative feedback well – not by the person who lashes back out at you. While an issue that doesn’t involve self-identity may be able to be resolved, once you engage the ego’s defenses, it may be impossible to move forward.

Guidance

The guidance may be clear, but it’s hard to pull off. Stay on the issue at hand and don’t share any inner judgement about the person who had the idea. If you’ve got to communicate about your perspective, focus on words like “I felt…” or “I think…” rather than “You said…” or “You did…” It’s too easy to trigger a response from the ego when you’re trying to speak for another person. Speaking for someone else can trigger the same identity protections as labeling them with some negative label.

When you’re working through a conflict, the best advice is to ensure that you don’t start to attack the other party no matter how frustrated you may get. Where possible, avoid using the word “you” at all – but particularly when preceded by “but.” This prevents potentially putting the other party into a defensive mode.

Conflicts shouldn’t be personal. Conflicts should be about getting to the best answer – there are people involved, but the people aren’t the problem. In fact, there are no problems. There are only different points of view.

Book Review-Better: A Surgeon’s Notes on Performance

I’m sometimes a hard guy to impress. Sometimes, I strive for excellence and look for ways to get better, and I forget to appreciate that good is good enough. Maybe that is why I appreciated Better: A Surgeon’s Notes on Performance so much. It certainly doesn’t hurt that I’d previously read and reviewed Atul Gawande’s Checklist Manifesto and Being Mortal. However, in the end, I think what I recognize in Gawande is that passion for making things better, because better is possible.

Medical Advances

From the dawn of medicine until relatively recently, doctors largely did their patients more harm than good. Techniques like bloodletting weakened patients when they needed their strength the most. Sometimes, even when advances were possible to move medicine forward, they were resisted. Ignac Semmelweis discovered the basis for germ theory in 1847 and the need to wash hands after working on cadavers or before helping mothers deliver their babies. Today, it’s positively obvious, but back then, it was unique and different.

There are numerous accounts for why Semmelweis was so ineffective at convincing his peers that germs existed, and that handwashing was sufficient to stop (or at least hinder) their spread. Most of them involve what are described as “personality defects.” Gawande reports that Semmelweis refused to defend or support his germ theory and instead resorted to personal attacks – which didn’t win him friends. (See Mastering Logical Fallacies for some of the techniques that may have made it difficult to take Semmelweis seriously.)

Handwashing and Antibiotic Resistance

Over 150 years after Semmelweis’ discovery, we still struggle to wash our hands effectively. Depending upon whose numbers you want to believe, handwashing compliance in acute care settings (mostly hospitals) is somewhere between 20% globally and between 50-80% in the United States. And we’ve tried everything to get those rates up. We’ve put alcohol stations at every door. The WHO has spent countless millions on campaigns like the “The 5 Moments” to teach providers when to wash their hands, and we’ve barely moved the needle. More importantly, we’ve not managed to improve patient outcomes – not one iota.

The consequences are terrifying. We’ve become so reliant on antibiotics that when antibiotic resistant strains of bacteria emerge, we’re caught flat-footed. In 1988, a Vancomycin-resistant enterococci (VRE) strain infested a renal dialysis unit in England, and by 1997, 23 percent of ICU patients were infected. Vancomycin is a go-to drug for infections, and when VRE adapted, we didn’t know what to do. In healthcare, we assume our antibiotics will save us – but when the bacteria adapt, we don’t know what to do. SARS (severe acute respiratory syndrome) was primarily spread through healthcare workers.

We fail to realize that the scary things that we must combat today aren’t fixable by an antibiotic. Take MRSA (Methicillin-resistant Staphylococcus aureus). Methicillin is another go-to drug that a bacterium found a way to resist. What’s scarier is that the newer strains – the ones that haven’t made the news yet – are resistant to not just one of our antibiotics but multiple of our wonder drugs.

When It Doesn’t Work

Medicine has changed war. Medicine has dramatically reduced the death toll in war. It’s reduced the mortality of both mother and child during childbirth. It’s made conditions that would have been fatal into outpatient surgery, yet it’s not enough. “The paradox at the heart of medical care is that it works so well, and yet never well enough,” writes Gawande.

It’s hard to have conversations in a group of people and not have someone tell a story of a loved one who died of a health issue. Too many of these stories involve complications that happened as a part of the medical care itself, whether it was an infection they didn’t have when they came in, a medical error, or just something that wasn’t an expected outcome.

As much as we have made progress, we’ve not been able to deliver the best care consistently.

It’s a Business

While it’s nostalgic to think of the doctor who serves a community, accepting livestock and services in trade for the healing he can offer, that’s not the world of today. Healthcare is a business – a big business (as is pointed out by Mistreated). As a business, doctors need to do what is necessary to keep the business going, and that may mean they stop helping people when doing so means you can’t afford to be in business.

The reality is that the skill of a surgeon in the operating suite has almost nothing to do with how much money they’ll make. Their ability to make a business run will drive their revenue and their professional survival as a doctor.

Follow the Rules and Innovate

It’s a double bind. On the one hand, we know there’s not enough application of the best practices that have been demonstrated through research. On the other hand, there’s no way to innovate if we don’t break some of the rules – in a controlled way – to see if we can make things better. This is the central concern at the heart of making medicine better.

On the one hand, we want doctors who read the latest journals and follow all the latest advice. On the other hand, we’ve seen research be reversed as new information is gained – and that information is only gained when we stray from the rules.

Clearly, the difference is that, in the one case, doctors fall upon the norms of their groups and just do what they’ve always been doing, even when there is research saying it’s ineffective or there are better approaches. It’s just too hard to override your experience. You’ve done sometimes hundreds of these procedures with only a few complications. Why should you have to learn something new? How many injuries would it really save? We don’t believe the research; we believe our personal experience.

So, we have to encourage consistency and simultaneously find ways to carefully try new ideas to see if we can get even better.

The Ego and the Average

At the end of the day, being better is about elevating yourself above the average. The only way to know if you’re making progress is to measure your performance, and that comes with a great risk. You may discover, much to your dismay, that you are only average, despite your striving and struggle. Despite the trials and the conquests, your performance is only average. While this may be, on the surface, bad news, it does at least let you know where you are. If you want to become better – as a surgeon or just in life – perhaps you should read Better.

Conflict: Our Beliefs About Others

We form beliefs about other people, and sometimes those beliefs aren’t right. When we have beliefs about people that aren’t correct or don’t match their beliefs about themselves, conflict is bound to erupt. The better we can manage our beliefs about other people, the more likely we are to avoid unnecessary conflict and resolve conflict quickly.

Fundamental Attribution Error

We all suffer from fundamental attribution error. We blame others for outcomes that were rightly based on circumstance not their character, but that doesn’t stop us. While we give ourselves grace, because we know the situation we were in. We don’t give the same grace to others.

Consider something as simple as someone who has had a divorce. Many people hold the value that marriage should be a sacred vow, and it should be forever. When we face our own divorce, we can rationalize that there was no way to make it work. We can point to the years of effort that we put into making it different. We can say that we reluctantly gave into the inevitable. However, when an acquaintance gets a divorce, we somehow think less of them. How is it that they could forgo their commitment so easily?

Of course, we have no idea how much effort or energy they put into keeping their commitments, and we don’t know that they weren’t faced with a spouse who was unfaithful, abusive, or absent. However, fundamental attribution error kicks in, and we think it’s something about their character.

Observations

All we ever have of someone else is observations of what they say and what they do. Of course, what they do is a better signal of what they really believe than what they say. However, we see their words and actions and from those must infer their intentions and values. We don’t know what they intended, but still we make up answers about what is going on in their inner world that may or may not have anything to do with reality.

Our observations themselves are only partial, and therefore we fail to see the whole picture. We see them snap at their child in line at the fast food restaurant but don’t see the two hours they spent trying to help their mother undo a malware attack. We see the inattentiveness at the grocery store but miss the fact that they just worked a double shift to cover for a friend whose father is in the hospital.

Values

From these partial and imperfect observations, we infer what we believe their values are. After all, if they’re willing to speak to their child that way, then family must not be very important to them. If they’re inattentive in the grocery store, then the way they eat must not be important to them.

The problem with this approach is that we don’t see the whole picture, and we don’t know what other competing values are in place. We see the person who fails to report an error because they’re worried their friend might lose their job because of it. They’re weighing their value of loyalty against the need for honesty – or righteousness. We only see the transgression, not the character strength.

Intentions

From these lofty ideas of their values, we establish what we believe to be their intentions towards us. Frequently, our belief is that they have negative intentions towards us. In most cases, the other person rarely thinks about us – and certainly doesn’t have an agenda to make our lives miserable – but that doesn’t stop our imagination.

Instead of believing the other person has the best of intentions, most of the time, we assume they’re out to get us.

Perspective on Us

What other people think of us is none of our business. It’s a fact that what other people think about us is as much about them as it is about us. They suffer from the same biases and limitations that we do, and they’re likely to not see us in as favorable a light as we see ourselves. As a result, when we arrive in a conflict, if we’re not really careful, we’ll each think less of the other person than we perceive of ourselves.

That sets the stage for a conflict based on nothing more than a misperception of one another – with or without a substantive issue to have a conflict about. If we can minimize our leaping to a belief that we understand the other person’s values and intentions and instead take a slow and thoughtful effort to validate the values and intentions we believe they have, we may just find that our conflicts disappear.

Book Review-Mistreated: Why We Think We’re Getting Good Health Care—and Why We’re Usually Wrong

It’s no secret that the American healthcare system is broken. While there have been great advances in healthcare that saves lives and improves the quality of lives for so many people, it is still broken. The problem is that we can’t take a step back and fix it because it’s still saving lives every day. Mistreated: Why We Think We’re Getting Good Health Care—and Why We’re Usually Wrong walks through the details of our healthcare system from blind spots and misperception to motivations that are out of alignment with what’s best for the public.

Confronting the Truth

It’s a convenient belief that we have the best healthcare system in the world. It’s convenient, because it fits the facts that we have the most expensive healthcare system in the world. More expensive means better, right? It’s convenient to believe we have the best healthcare system in the world, because we send our loved ones to get healed here, and we want the best for them. We ourselves get our care here, and why wouldn’t we want the best?

The problem is, while it’s convenient to think we have the best healthcare system in the world, that’s far from true. We have “the highest infant mortality rate, the lowest life expectancy, and most preventable deaths per capita” of the modern world. While we spend the most on healthcare, our results are far from the top of the pack. Instead, our system invites waste, greed, and poor outcomes, all the while believing the care we receive is good. At some level, we know that this is lunacy, but it’s a convenient thought that keeps us from confronting the truth. Seventy-six percent of people describe the quality of their care as good or excellent. This statistically can’t be true.

Affordable Care Act

The Affordable Care Act (ACA) is the most sweeping set of healthcare reform that has been done in decades. While focused on making it easier for every American to have access to healthcare, it was able to address some other issues as well. No longer would people be denied insurance because of a preexisting condition. Preventative care was made nearly or completely without cost to the consumer.

While this was important legislation, it didn’t strike at the heart of the structural problems healthcare faces. We pay for services instead of paying for health. We’ve not been able – yet – to transform the relationship to one where the consumer only pays for results. This change can make all the difference.

Unnecessary Surgery

If pain is the symptom, surgery rarely has better outcomes than alternative treatments. Yet we perform surgery to repair a torn meniscus and place stents in people’s arteries at great cost with little or no actual health benefit. The results are in – and they say we shouldn’t do them. Like dozens of other treatments that are ineffective, we still do them because it’s standard practice or because they’re marketed aggressively.

Opioids

There’s a bit of news now about how opioid manufacturers, particularly Purdue Pharmaceuticals, engaged in aggressive marketing of Oxycontin, which had a high potential for abuse but which the company routinely led physicians to believe was safe. Dreamland covers this aspect of our healthcare woes in detail. The short version is that we began treating pain as a vital sign, and physicians began getting more directly measured by their intentionality about treating pain. In most cases, this meant prescribing them a pill.

Pharmaceutical companies learned that, when marketed to them directly, consumers would ask their doctors for the medication. Often, they’d get what they ask for. Doctors are reluctant to deny their patients the medications they’re asking for – even when it’s not effective. Consider the over-prescription of antibiotics. A patient doesn’t feel well, and they make the decision to go to the doctor. They expect the physician will do something to make them better. They expect they’ll get a pill that will make them better. The physician, tired of explaining that an antibiotic won’t help, prescribes it anyway, knowing it won’t make them better. In the next week, the patient feels better and attributes their wellness to the drug – instead of to the virus running its course.

We see this desire of the public to just get a pill and fix it show up in every aspect of healthcare, including mental health, where it’s easier to take an anti-depressant than to deal with the underlying problem. (See Warning: Psychiatry Can Be Hazardous to Your Mental Health for more.)

Generalists and Specialists

The frequency with which you deal with a problem makes a big difference in your outcomes. The truth of the matter is that in medicine – like many other disciplines – you can’t get good at something if you’re never given enough time to practice and learn. Intuitively, it makes sense. If you do one gall bladder surgery a month, you’re not going to be as skilled at it as someone who does 100 a month. However, in most cases, the market doesn’t allow physicians to become hyper-specialized into a single kind of surgical procedure. Even our specialists cover a wide range of procedures and patient problems – too wide to drive the kind of volume in the procedure that would make them truly good at their craft.

What tends to happen is that a generalist treats a few patients a month and gets, at best, middling results from them. Even the specialist can’t afford to be hyper-specialized, because all the generalists are taking the cases they need to stay fully busy and get very good at what they do.

That’s not to say that generalists, like your primary care physician, are bad or not needed. It is believed (based on successes in other nations) that the best solution to the healthcare performance problem in America is to get primary care physicians better at preventative medicine – true health care – instead of trying to triage and route patients who are truly sick.

There’s a very old saying that “a stitch in time saves nine.” Meaning if we catch things early – like before they start – it takes very little to maintain or repair the situation. The later we catch a problem, the more challenging the recovery becomes – but that’s what we reward in our current system. Specialists (such as they are) are paid roughly three times what primary care physicians are paid. We undervalue the preventative measures that can have the greatest impact, and we elevate the heroic, last-minute attempts to help someone survive.

Undervalued

There’s a real soft spot in my heart for the understanding that we undervalue simple interventions that save lives and instead invest our money into technological marvels that have little or no real impact on outcomes. Another big marketing tool that healthcare systems are using is robotic surgery. Again, it makes sense. Doctors’ hands can be shaky, but robotic hands are not. However, the efficacy for robotic surgery isn’t any better than regular surgery – oh, and it takes longer. However, organizations are spending millions of dollars on these robotic surgery devices, which sit idle most of the time. Physicians want to have them but don’t see any need to make their jobs harder without better outcomes.

The soft spot for me comes because of our IV dressing patent. It’s simple. It’s straightforward. And we’re still trying to get the market to accept a change that may impact materials cost by $1 and may substantially reduce healthcare-associated infections (HAIs). It’s not sexy, but it seems to work. That may be why it’s not being used. Because, in the upside-down system of American healthcare, if it doesn’t seem like it’s cool, then it’s not worth doing.

Dr. Pearl shares his appreciation for information technologies and the ability for these simple technologies to improve outcomes.

Diabetes Advantage Program

It seems like a lifetime ago to me now. The study was being done in 1999, and the journal article was about the program titled “A Systematic Approach to Risk Stratification and Intervention Within a Managed Care Environment Improves Diabetes Outcomes and Patient Satisfaction” in Diabetes Care (Volume 24, Number 6, June 2001). The short version is we took patients with diabetes who were being treated by primary care providers, and we gave the primary care providers suggestions for the actions they should take to help their patient better manage the disease. We basically made it easy for the physicians to do the right thing.

The recommendations would print out to add another oral medication, the nurse would write a more specific recommendation in based on the physician and the specific drugs the patient was on, and the physician would sign the orders. The physicians quickly learned to trust the system (and the nurse). They realized the system was giving their patients the benefits of the best research on the disease without them having to study it.

The net result was about a 1-point drop in HbA1c values in 12 months. To put that in perspective, back then, the threshold for having diabetes was 6, and the threshold for uncontrolled diabetes was 8. (These values have been adjusted a bit in more recent standards.) So, a 1-point drop in HbA1c values was a substantial change. Most of that change is attributable to the system “reminding” physicians to do what the research suggested was best.

In short, helping caregivers with information technology works – and we’ve known it works for decades now.

Environment of Care

We tend to overestimate our rational rider and underestimate how much of what we do is shaped by the environments that we are in. Kurt Lewin proposed that human behavior is a function of both person and environment. You can’t predict what a person will do without understanding both. More recently, we’ve seen how people can be made to do awful things to other people with relatively little encouragement. The Nazi extermination of Jews was unfathomable. However, as both Albert Bandura (in Moral Disengagement) and Philip Zimbardo (in The Lucifer Effect) explain, it’s relatively easy to disengage our morality and cause people to behave in ways that don’t make rational sense. They both point to the work of Stanley Milgram after World War II, in which subjects were thought to be giving progressively higher voltage shocks to another subject in the next room. Most continued to give shocks that they perceived to be potentially fatal with little more enticement than knowing it was for the experiment.

It’s surprising how little factors can cause us to take different behaviors. Nudge uses numerous examples of how changing the easy or default answer changes the way people eat and save. When you look at the body of literature around change, you’ll find that, much of the time, making change work is about a few well-placed interventions. (See Switch, Redirect, Change or Die, Change Anything, Made to Stick for examples.)

These same factors hold true whether we’re talking about something truly evil or we’re simply talking about practices that aren’t effective. Once the group establishes a social norm, it’s hard for new people to adjust the norm, even when the new target has better demonstrated outcomes. In short, the team becomes fixed in their perspective and don’t accept the valuable input from the outside. (See Diffusion of Innovations and Hackman’s Collaborative Intelligence for more on the receptiveness of a group or team to outside influence.)

Sometimes, the best examples of what to do are sitting right under our noses. The Washington Post Magazine arranged for internationally-acclaimed virtuoso Joshua Bell to play his violin at a subway stop for spare change. The man who played for presidents and sold out concert halls earned a little more than $32 in his time at the subway station. The expectation that he was simply a street player led nearly everyone to treat him as one. The environment we’re in really does dictate how people respond to us.

Healthcare Is a Team Sport

In America, we’re enamored with the idea of a lone hero charging across the western plains to conquer a new land. The wagon trains of families banding together to face the hostile wilderness just doesn’t sell as well. We want to believe the surgeon has better outcomes while ignoring the impact of the hospital, the nurses, and even the janitors. In healthcare, janitors are called environmental services (EVS) workers. The painful fact is that most EVS workers clean somewhere between 30-50% of the things they’re supposed to clean between patients.

There’s a growing body of research that shows pathogens are being passed from one patient to the next because of improper or incomplete cleaning. Moving the needle from 50% to 80% of the objects cleaned can have a reduction in HAIs of about 20%. To put that in perspective, that’s more than one infection saved per EVS worker per year.

Nursing, too, has been shown to have a critical role in the outcomes for the patient. “Better” nursing care is associated with better outcomes. Subtle things like the degree of burnout nurses experience has an impact on the patient outcomes.

Everywhere we look, there is evidence that it’s more than the gifted surgeon that makes the difference in the outcomes. Now more than ever, healthcare is a team sport – and one that is sure to continue. The silent member of the team – but the one that is always present – is the patient.

Patient Non-compliance

One frustrating aspect of healthcare is that frequently the patient is non-compliant with the protocols they’ve been given by the healthcare staff. Whether that’s failing to take medications or it’s not doing the prescribed exercises, getting the patient to behave in their best interests is often a frustratingly difficult challenge. To be fair, most of the challenges here are ones that educational folks have learned to address but healthcare hasn’t picked up on.

Healthcare workers aren’t careful about educating patients and asking questions for which the correct answer is no. By default, humans will answer yes if we don’t understand. So, asking questions that have no as answers can help ensure the patient understands. (See Incognito, Predictably Irrational, and The Hidden Brain for more.) For instance, instead of asking “Do you understand that you should take this with a meal?” you might ask “So, do you believe you should you take this on an empty stomach?” Healthcare workers suffer from the curse of knowledge, which means they fail to explain in a way that patients can understand. (See The Art of Explanation for more.)

What’s more, healthcare workers haven’t been taught to give patients productivity aids to help make them more successful. (See Job Aids and Performance Support for more.) The handouts they give patients are largely unintelligible even by healthcare workers, and they aren’t inviting to someone who’s unfamiliar with healthcare and what’s happening to them. Beyond the paper they’re given, they’re rarely pointed towards tools that can help them be more compliant – like an application for their smart phone that will remind them when it’s time to take medications.

If we’re going to make healthcare better, we’ve got a long way to go. We’ve got to address the motivators that cause people to take advantage of others. We’ve got to move towards higher specialization and more preventative medicine. And we need to get everyone on the team – including the patient – so we can prevent more people from being Mistreated.

Conflict: Relational Bank Account

At some point in our lives, nearly everyone has overdrawn their financial bank account. Whether it’s oversight, an error, or the fact that there just wasn’t enough to go around, nearly everyone has done it at least once. The trick with bank accounts is to rarely overdraw them. It’s not like you can’t ever do it, it’s just costly when it happens. In conflict, we’re not talking about financial bank accounts, we’re talking about relational bank accounts. Relational bank accounts are based on what you’ve done for others and the trust and respect you’ve built up that allows you to more easily weather the storms that you face.

Making Deposits

You don’t always get an opportunity to start a relational bank account with deposits, but you often do. Coworkers, colleagues, managers, and subordinates rarely enter the picture on the first day with a conflict. Instead, they often spend hours, days, weeks, months, or even years before the first substantive disagreement occurs. During the intervening time, we can make deposits into our relational bank account.

Those deposits are the things that we do to build trust, respect, and good will. It can be something as simple as saying hi or as caring as sending flowers when they’ve lost a good friend or family member. It’s doing simple things that build relationships, so that trust, respect, and good will are the natural outcomes.

Making Withdrawals

Everyone makes withdrawals from their relational accounts, too. Sometimes, it’s a hard word. Other times, it’s a hard decision that the other person doesn’t perceive as fair or caring. We’re not going to have relationships from which we make no withdrawals; that’s not how relationships work. The important aspect is to recognize the withdrawals and, where possible, make additional deposits to cover the withdrawal, just like you might do with a real bank account.

Accruing Interest

The good news about relational bank accounts is that they generally accrue interest when they’re not being withdrawn from. Take the childhood friend whom you’ve not seen in a decade or more. Your response to them is likely to be even more positive than it would have been when you last saw them. The standard flow of time will make the relational bank account grow, not shrink, over time.

Of course, there are ways the passage of time has a negative effect on a relationship, but most people’s experience shows that time is on your side.

Certificates of Deposit

You won’t be able to get a certificate of the deposits you’re making into the relational bank account. However, you will be able to get a sense of how you can lean on a relationship when you’re in a conflict with the person. The greater your relational bank account balance, the greater the likelihood the other person will trust you, respect you, and have a substantial amount of good will that may make the actual conflict trivial.

Having large relational bank account balances allows you to put conflicts in perspective and realize that, though there’s a disagreement – a difference of opinion – in the broader picture, you and the other person are both good and have the best intentions. That’s often nearly enough to neutralize the conflict.

Relationship Calculus

No one wants to believe we’re making a value judgement with every relationship we’re in. It feels impersonal. It feels like, if the other person doesn’t measure up, we’ll cut them out of our lives. That in turn means they may choose to cut us out of their lives. It a yucky feeling that no one wants to feel. Despite this, there is a calculus that we’re unconsciously performing when we’re in relationships. We’re evaluating whether this relationship is something we want to continue or not.

Give and Get

The basic math behind relationships is a simple inequality. We are looking to get as much as – or more than – we give from the relationship. It sounds like this would make everyone selfish and only out for themselves and not others. However, there are two reasons why this isn’t the case. First, how we value our efforts and the things we get from others isn’t even. We can greatly value something someone else does for us that’s easy for them.

Second, what we get isn’t always from the other person. Sometimes what we get is a greater sense of being the kind of person we want to be. We do things for others not because we expect to get something back from them but because we get a sense of peace, power, or belonging that we find valuable.

With this as a foundation, we can explore how we view what we give and what we get.

Giving

With my background in technology and particularly Microsoft Office applications, I know things that I’m not even aware I know. I will routinely press a key or activate a feature in Microsoft Word that people around me have never seen. When I’m asked about it, I happily share the information, and they’re richer for it. The cost to me is trivial. It’s something I can give with a few seconds of time.

Sometimes what I can offer is more expensive. The chief cost of giving is the time it takes. Certainly, there are some things that have a material cost, but for most of us, those costs can be converted into the amount of time it would take us to earn that money. Ultimately, the time we invest in others, through time spent with them, doing things for them, giving things to them, etc., is just as important as if we had invested in material things.

Getting Externally

A friend comes over to help you diagnose a problem with the air conditioner. You know nothing about it but he’s an expert. It takes only minutes for him to find a problem with an inexpensive relay that he happens to have with him. An emergency call to a heating and cooling contractor would have been hundreds of dollars – and hours of waiting on them to arrive. Your friend spends a handful of minutes and a few dollars for the part. However, the value to you is substantially greater.

That’s the primary imbalance that allows relationships to function. Sometimes, you give a little, and they get a lot. Sometimes, they give a little, and you get a lot. Because of specialization and the reality that we each have unique skills that we can share the benefits of with others, we create the opportunity to get more than we give – from a perception point of view.

Getting Internally

There’s a certain sense of peace that you get when you know you’re able to help others, even when you know they’ll never be able to repay you. It’s a sort of karma. You believe more firmly that others will be there to help you in your time of need when you’re able to do that for others. So, paradoxically, when you’re giving to someone who may never be able to repay you, you’re getting internal validation that the world is becoming more like the world you want to see in life. You don’t need to receive anything externally, because you’re getting the value from giving. In effect, the relationship with the other parties is about having a better relationship with yourself.

Simulating Relationships

The entire idea of compassion and generosity doesn’t seem to make much sense. If Darwin’s survival of the fittest were operating, wouldn’t it make sense that the fittest would be looking out for themselves? As it turns out, no. Cooperation is a powerful tool for surviving and allowing one’s genes to propagate. Even self-sacrifice to the point of death can pass along genes through the relatives who, through your selfless act, are still alive.

Robert Axelrod performed a series of competitions for programs to make a rather simple decision about how generous or greedy that they’d be. The competition was setup with the prisoner’s dilemma. The short version is two criminals are captured. If they both stay loyal to each other, both will get three years. If one defects (offers evidence on the other), they’ll get one year and the other will get five years in jail. If they both defect, they both get five years of prison. In this configuration, an agent – program or person – should always defect, because it creates the best outcome for them personally when the other party’s behavior is unknown. However, that’s not what was the most effective for both in the simulations. Generosity and an attempt to get to the best outcomes for both sides won the competitions. In short, start with the assumption that the other side won’t defect and only defect to retaliate against the other party.

Evolution, it seems, may not work on survival of the fittest at an individual level. Rather, it may be that evolution works on survival of the fittest at a group level. This can explain generosity and a desire to be good to others – because doing so makes it more likely that your group will survive.

Trade Imbalance

While it’s possible to get more – either externally or internally – than you give, the reverse is also true. Consider the effort to put together a delicious and nutritious meal, and a family who doesn’t care. They’d be just fine with warmed Spaghetti-Os and hotdogs. Your gourmet meal is lost on them – just like the time spent preparing it. In trade imbalances like these, the best thing is to just stop doing the things that lead to the imbalance.

That’s sometimes easier said than done, as people still need to be fed, and you may not be okay yourself with making such a simple dinner. The result is a need to find a way to renegotiate what you’re doing – and why you’re doing it. You may decide that the gourmet dinners are for you and not them anyway.

Trust

Relationships are all built on trust – even if the trust is that the other person will always do what is in their personal best interests regardless of whether it’s in your best interests or not. Trust is the mechanism by which we evaluate our contributions to a relationship – we trust they’ll acknowledge the contributions – and the way we evaluate what we’ll get. We believe that the person will be there to help us out in our time of need.

Timing

Another consideration is our belief may be predicated on the expectation that, in the end, we’ll get more from the relationship than we put into it – but over what time scale? When you’re putting in extra effort to help a friend as they’re struggling with a death or a divorce, do you expect that you’ll receive as much as you’re giving? The answer’s probably no.

However, if you believe that the other person has already given you much more than you can ever repay – or you feel like they’ll be there when you need them – then the momentary imbalance in what you’re giving vs. what you’re getting may be completely appropriate.

Predicting the Return on Investment

These factors make up our assessment of the return on investment we’ll receive from a relationship – or the amount we feel we owe the other party for their previous support of us. The problem in the way we predict the return on investment in relationships exists in the biases we all have. We can fall into negative confirmation bias where we fail to see any value in the what the other person is doing in the relationship. We can similarly be in positive confirmation bias and be blissfully unaware of how the other person is taking advantage of us.

We can discount what the other person has done for us in the past. We can disbelieve they’ll help us in the future – or we can be sorely disappointed, when we trust someone else will come through for us, and they don’t.

There’s no perfect answer to whether a relationship is valuable or not – there’s only the awareness of some of the factors that are involved in the equation.