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Book Review

Book Review-Exit, Voice, and Loyalty: Responses to Decline in Firms, Organizations, and States

You only have two options when you’re experiencing a problem and you want to change it.  You can exit the situation, or you can use your voice to try to try to change it.  In 1970, Albert Hirschman wrote Exit, Voice, and Loyalty: Responses to Decline in Firms, Organizations, and States to explain how these two forces could help to drive forward commerce and politics – and the conditions under which these forces might not be enough.  The inclusion of loyalty was because it’s a mediating factor that influences when exit is used compared to when voice is used.  What makes Hirschman’s work interesting is that it applies not just to commerce and politics.  It applies to life.  It applies to every relationship that we have with organizations and others.

There’s a fundamental premise behind the book, which is that things are – at all times – somewhat imperfect and need some process to combat the process of entropy and degeneration.  This is, in nearly every aspect of our human existence, truth.  We recognize that, without market forces, organizations will reduce quality – a concept Hirschman is focused on – or will raise prices to the point that they can.  This is the heart of the monopoly protections that the government puts in place when competition is removed.  It’s also why anti-trust laws exist to prohibit collusion that might suppress the forces of exit and voice that Hirschman explores.

The Options

There’s a third option that doesn’t make it to the marquee of the book.  The option is to do nothing.  However, it isn’t an option that steers the relationship in a positive direction, it simply blindly hopes that the situation will get better – and it’s the option that loyalty, in its most extreme form, results in.

The economic premise of exit is that if you withdraw your commerce from the organization, its monitoring systems will detect the loss of revenue and awaken leadership to changing the organization in a way that corrects the reasons for the exit.

Voice, on the other hand, seeks to provide feedback directly to the organization in a way that doesn’t involve economic harm.  The basic premise is that the leadership of the organization is actively interested in the feedback of the customers, members, or citizens such that their feedback forms a first signal before exit becomes the required option.

The Mitigating Factors

At the individual level, we each have biases toward choosing to exit or apply our voice to a situation.  In the United States, our history has been largely influenced by the key decisions to exit.  It’s no wonder why, at a broader level, Americans seem more willing to exit an organizational relationship than to apply their voice.  However, there are two key mitigating factors for choosing voice over exit.

The first is the issue of loyalty.  The more loyal we are to a brand, the more likely we are to provide feedback directly via voice rather than leave.  Look at this 2×2 grid, which places loyalty and the degree to which the organization is listening on axes:

Loyalty for an organization with high listening results in change and therefore high retention.  However, for the organization with high loyalty and poor listening systems designed to pick up the voice of the customer, the result is repeated frustration by those who are loyal to the organization.  In the low loyalty category, low listening results in rapid exit as customers need little proof that their best option is to exit.  With low loyalty and high listening, organizations are confused why there seems to be nothing to hear.  Many customers exit without even attempting to assert their voice.

However, this graph ignores the other mitigating factor that constrains exit.  The greater the cost there is for switching, the greater the resistance of the exit option and thus the greater willingness to test voice as a vehicle for change.  High costs of changing were an intentional strategy of wireless carriers in the past.  Once a person was with you, they would be retained for a very long time, because the cost of switching was so high.  Gradually these barriers to exit were brought down by governmental and market factors.  Phone number portability transferred the ownership of a number from the carrier to the subscriber allowing them to take the number with them to another provider.  Market moves like those of T-Mobile pushed against the long-term contracts.

When There is No Escape

In some cases, the cost of exit is so high that it practically becomes impossible.  In the case of political systems, it’s possible to leave the city, county, state, or nation but at progressively higher and higher costs.  These costs are impractical to most people.  Highly constrained on the availability of exit, the result is voice – sometimes voices in active protest.  With exit constrained, more energy can be invested in voice before people exhaust their patience.

Once patience with voice has been lost, the consumer will fall into a trapped, hopeless place where they no longer see any escape from their circumstances.  This is problematic in two directions.  First, being resigned that nothing can change, they no longer provide any direct input into the system for the organization to learn.  The second direction is that pressure continues to build until a nontraditional solution for exit or organization change is attempted, often with disastrous consequences.

When There is No Voice

An opposite condition can occur when exit is too easy.  It’s effectively costless to transition, and the exit happens without any signal to the organization.  The result is that the voice option – the voice of the customer – becomes mute; no one bothers to offer up a voice, since doing so serves no purpose.  Thus, loyalty mediates this problem in environments where exit is too easy.  It encourages the use of voice where normally there would be none.  We can see this in the airline loyalty programs.  The programs are designed to keep flyers on an airline instead of exiting.  Even in an environment where the time and costs should dictate the transactions, we find that loyal flyers go out of their way to continue to fly on their preferred airline.  More importantly, they expect that they have a voice that will be heard.

The escalation teams for customer service issues at most major consumer organizations are named as “executive” care teams.  The implication is that you’re getting the special treatment that only the most important people receive.  Having engaged with many of these teams in the past, I can tell you that their efficacy for addressing problems is lousy.  They’re happy to issue a credit, but when you need a service problem resolved, they can almost never help.

The Impact of Time

Buried at the end of Hirschman’s treatise is that there are, in some cases, hybrid versions of each.  For instance, the boycott, where there’s a temporary exit.  The service is intentionally avoided for a period of time even if long-term avoidance is impractical.  More critically, he addresses the fact that loyalty has its limits.  Loyalty doesn’t fundamentally change the cost/quality to retention ratio.  Instead, it introduces a temporal dimension that is often ignored.  We’ll tolerate poor service from our favorite restaurant occasionally.  We may do so and neither resort to exit nor voice.  We’ll just expect they’re having an off day.  The degree to which we’re willing to do this is largely driven by loyalty.

A single stop at a restaurant with poor service will likely cause us to avoid it – exercising exit and not bothering with voice due to the low cost of changing.  It’s the loyalty that keeps us coming back – or using voice when no exit cost exists.  However, each time we encounter poor service, our loyalty will be a bit less – eventually, it’s not enough to hold back our desire for exit.

Desire of Autonomy

In some conditions, it may be desirable for an organization or its leadership to assert a level of autonomy.  That is to say, they may want to dispense with all the messy feedback and painful review of the metrics that are moved by the exit of customers.  They may thereby insulate themselves from the voice of the customer and remove the important leading metrics from their dashboards so that they can set out on their own course of change for the organization.  While this can result in success, it’s quite dangerous and ill-advised in all but exceptional circumstances.

Take the story of Netflix and its desire to separate its DVD shipping business from the online delivery of movies.  The attempt was a disaster – which was quickly remedied, to its credit.  However, it is a good example of an internal decision that wasn’t subjected to the review of loyal customers before it was announced publicly and received a negative reaction.

The MVP Program

I remain honored to be a part of the Microsoft MVP program.  It has taught me a lot about the sausage-making of building software products.  It’s also taught me that sometimes the voice that we’re graciously granted doesn’t change products.  Instead, it shapes how Microsoft announces their products to the broader market.  We often notify the product teams of the kinds of resistance they can expect in the market, and that allows them to shape how they message the changes.  While this isn’t the change that I hope to accomplish via my voice, I know that it serves an important role for the organization.  They need high-fidelity feedback channels that will tell them when they’re off the rails.  Sometimes, they can pick the train back up and put it on the rails again.  Other times, they paint the wreck in pretty colors and hope the market doesn’t notice.


It’s important to revisit the concept of politics and the degree to which the option of exit is limited in politics.  It’s hard to leave.  Even in boundary places, where exit appears to be available without undue costs, there are hidden costs which must still be paid.  Hirschman explains that consumers are free to send their children to private schools, but in doing so, they deprive the public schools of the most powerful voices in change.  Even those who send their children to public schools must still contend with the rest of the community who has received sub-standard education – so, at some level, they cannot escape (exit) the challenges of poor schools.

Politics is a special place where the cost of exit is so high that voice is nearly the only solution.

Sunk Cost and Skipping Rocks

One of the dynamics that Hirschman explores is the interplay between loyalty and exit.  This is a place where our sunk cost fallacy may drive the same direction as loyalty.  In Thinking, Fast and Slow, Daniel Kahneman explains that we tend to keep investing once we’ve made an initial investment – even when further investment isn’t the right answer.  We see this with employees.  They tend to either have a short tenure with an organization or a long tenure.  Once an employee has passed to a point of having worked at an organization for a few years, they’re invested and are much more likely to carefully use their voice to try to initiate change.  (See The Art of Insubordination for ways to do this.)  Employees without tenure with the organization have no sunk cost fallacy and therefore may decide that exit is their best option when confronted with an issue.

The lesson for HR managers is that their attempts to build loyalty should be equally distributed to include new employees.  Tenure-based bonuses may be a good reward, but they do little to encourage loyalty of the newest employees – and therefore is an area that may be challenging from a turnover perspective.


While the entire context of the book lives in the realm of our society, including our organizations, affiliations, and politics, there’s one important aspect of Hirschman’s work that bears exploration.  He mentions only briefly about these options in families, yet it’s another important part of our lives, and one where the forces and options apply with perhaps greater impact.

To start, the book Divorce notes that after “irreconcilable differences” became an option to initiate divorce, there was a sharp rise in divorces.  In the context of Exit, Voice, and Loyalty, when the exit was made an option, people took it.  Alternatively, you could say that the cost was lowered; however, substantial stigma and therefore cost remained.  In short, the high cost of divorce maintained marriages that would have otherwise fallen apart.

However, there’s more.  If you evaluate Hirschman’s work in the context of estrangement, like those discussed in Fault Lines, one can see that either there’s a low value to the family relationships or a low loyalty to family – or both.  This leads us to Francis Fukuyama’s work in Trust and how different degrees of trust shape society.  Specifically, Fukuyama’s use of trust incorporates a degree of loyalty in it – and thereby changes the way that individuals react in families and in society.

What Hirschman views as competing options of exit and voice, Harriet Lerner views as The Dance of Connection.  In her book, she thinks about how to use voice effectively, and when it’s time to exit a relationship.  The principles drive all our relationships.  The challenge in the sense of relationships is that our exercise of voice sometimes causes the other person to exit – whether the voice was used appropriately or not.  Similarly, the market conditions for connections in our hyper-connected world are plentiful, and therefore the cost of exit seems small.  Smaller than it should when we recognize that at the heart of what it means to be human is to be connected, and those connections are intended to be substantially deeper than the world we live in today with Facebook friends.  Maybe it’s time to find out more about Exit, Voice, and Loyalty.

Book Review-Finding Meaning: The Sixth Stage of Grief

Grief sucks.  Finding a way out from underneath the weight is the goal.  That’s what David Kessler proposes in Finding Meaning: The Sixth Stage of Grief.  How do you learn to grieve in ways that avoid suffering and allow you to find some meaning in the aftermath of loss?  Kessler argues that finding meaning helps to transform grief so that it’s less painful and less suffering.

The Grieving Process

Kessler’s previous books include co-author Elizabeth Kubler-Ross.  Kubler-Ross wrote On Death and Dying, a classic about how people respond to the prospects of their own death, which she and Kessler adapted to the grieving process in On Grief and Grieving (which I’ve not reviewed).  Not everyone is wildly supportive of this work and approach to both death and grieving for various reasons.  However, as I explained while defending it against the concerns leveled in The Grief Recovery Handbook, it’s solid work that’s often misunderstood.

Grieving doesn’t follow a single linear path from start to finish with regular checkpoints along the way.  Instead, grief is a deeply personal process that has no one answer.  One moment you’re accepting things, and the next you’re throwing things in frustration, desperation, and denial.  This is sometimes confusing to those who are going through it – or those close to them.  After a moment or month of return to denial, it’s hard not to question what progress looks like and whether things are headed in the right direction.  However, that’s not giving the grieving both the benefit of the doubt – and the space to grieve in their own way and their own time.

Nothing Prepares You

Candy Lightner formed Mothers Against Drunk Driving (MADD) after the death of her daughter Cari at the hands of a repeat drunk driver.  John Walsh started America’s Most Wanted after the abduction and murder of his son.  Neither desired the tragedy – but they decided to make the best of it in hopes that others wouldn’t have to go through what they went through.  Knowing intimately the pain and torment of the loss of a child, they decided that no one else should have to.  They found meaning in a purpose.  They developed their grief into a force to prevent others from having to feel it.

Even those who have spent their lives teaching and writing on a topic can find themselves unprepared when it happens to them.  Kessler explains that he lost his 21-year-old son and how none of the work he had done teaching people about grief was enough to prevent his own loss.  He may have handled it better than most – but it wasn’t as if he managed to side-step the grief process.  What he did know was where all the signposts were.

Sense Making

One of the things that we know about humans is that we have a deep need for things to make sense.  If prediction is the fundamental purpose of consciousness, then we need sense-making to feed the prediction engine.  (See Mindreading for more about the belief that prediction is the fundamental purpose of consciousness.)  We know that we learn and think in stories.  (See Story Genius and Wired for Story for more.)  We even recognize the role that sense-making plays in whether someone will emerge from a trauma with growth or post-traumatic stress disorder (PTSD).  (See Transformed by Trauma, Opening Up, and The Body Keeps the Score for more on how sense-making relieves PTSD)

It’s no surprise, then, that to transform a trauma of the loss of a loved one, we need to make sense of it.  What is surprising is what that sense can mean.  It can transform someone from believing the world is a fundamentally helpful place to a view that the world is fundamentally hostile, and it’s necessary to protect oneself.  This is a fundamental belief, because it’s not easily changed – but the loss of a loved one is just the size of trauma it might take to shift it.

Conversely, the sense-making can be much, much smaller.  It can be that you develop an avoidance for the source of the trauma.  If your husband died in a motorcycle accident, you may develop a strong aversion to motorcycles.  The sense that you make from the trauma is personal, and it likely will never answer the question about why your loved one had to be the one.

Meaning Is What You Make of It

Meaning is what you make of the tragedy.  It can be a quest to change the world to make it better or form connections with others who’ve suffered similar tragedies.  The meaning you make isn’t the same meaning that someone else would make.

Love and Grief

It is possible to avoid grief – but at what cost?  Grief is the way that we experience loss.  It’s possible to avoid loss only through the avoidance of learning to love others.  If we don’t care about others, then we can avoid grief.  In the moments of deepest mourning and grief, we may briefly decide that this sounds like a good plan only to realize it’s a fool’s errand.  Love is what makes life worth living.  It’s the light in the darkness that we sometimes see in the world.

To be clear, love here is the relationship and connection that you have with others.  It might be the Greek eros (sexual love), but it’s more often philos (brotherly love) or agape (world love or compassion).  The Grief Recovery Handbook appropriately points out that grief is the way that we respond to loss, and therefore it doesn’t necessarily have to be related to love – but it often is.

Acceptance and Non-Judgement

The divorce rate of parents who have lost a child is high – too high.  Kessler attributes this to the fact that the spouses grieve differently, and they don’t allow for their partner’s grief in a way that accepts and validates it.  We believe the way that we grieve – as influenced by our societies, families, and personal experiences – is the way that everyone should grieve, and we’re confused when our spouse doesn’t grieve this way.

David Richo suggests that there are five As that we need in his book How to Be an Adult in Relationships.  Those As are attention, acceptance, appreciation, affection, and allowing.  Perhaps if everyone practiced these, we wouldn’t have to compound the tragedy of death of a child with the tragedy of divorce.  (See more about Divorce.)

Addicted to Grief

Capture speaks of how our processing of a situation or our life can leave us stuck.  It’s as if our loss has taken the wheel, and we’ve become helpless passengers on the journey of grief.  The process isn’t fundamentally different from the process of addiction, where someone starts with a coping strategy that progressively gains more and more control over them.  Some people can become stuck in their grief process, swallowed up by the support that we receive to the point that we fail to stand on our own or attempt to regain control of our lives.

While it’s natural to be utterly overwhelmed and unable to function after a loss, at some point, we’ve each got to figure out how we can work on our own healing.  No one can heal us – it’s something that we must do ourselves and it’s not easy.  The healing that we muster doesn’t mean our loss didn’t happen or won’t impact us, but it does mean that it no longer controls and confines us.

Suffering is Optional

Kessler argues that grief is necessary, but suffering is optional.  I agree in part – but disagree as well.  The word suffering is “the state of undergoing pain, distress, or hardship.”  The losses that we’re speaking of necessarily cause suffering.  However, where I agree with Kessler is that the amount of time you spend in suffering can be influenced.  You can choose to remain in a state of persistent suffering, or you can crawl and climb your way out of the hole that is suffering.

Those who have lost someone are caught between two incompatible expectations.  On the one hand, they’re expected to return to “normal” as soon as possible.  People wonder if you’re “over it” yet.  On the other hand, we’re told the degree to which we grieve is the degree to which we loved the person we’ve lost.  In that case, shouldn’t we go on grieving forever?

The truth is that we will continue to grieve forever.  It will change and transform, but it will always be there.  We can choose to have the expression of our grief be pain and distress or we can simply experience it as a loss.

Why Me and What Do I Do Now?

There are two different ways to questions we ask ourselves in any loss – and we all use both at different times and to varying degrees.  The first approach is to ask the question, “Why me?”  This comes from a place of victimhood.  Why was I the victim of this unfair event?  The answer that life isn’t fair isn’t very satisfying.  While the question is reasonable and expected, you don’t want to build a home in victimhood.  (See Hostage at the Table for more on victimhood.)

The other question is, “What do I do now?” which represents an awareness of the agency we have in how we respond to the events that happen in our lives.  Losses happen that we have no control of.  We must simply accept they’ve happened no matter how painful they are or how much we want to avoid the outcome.  While losses aren’t controllable, the way that we react to them is.  Certainly, we should mourn the loss and grieve but we can choose for how long and in what ways.

That isn’t to say that we have conscious control of our grieving process, and we can decide that, on Tuesday at 3:02 PM, we’re done.  Instead, we control the responses in a way that encourages our recovery or leaves us in the same place of victimhood.

Life Worth Living

The person that we’ve lost can no longer be present for life.  Their death ends their participation.  However, we have a choice as to whether we are just going to be present for life or whether we’re going to find ways to make the best of what we have left – to thrive as much as is possible.  (See Flourish and The How of Happiness for more.)

Running into the Storm

Imagine for a moment that you’re out on the plains on a motorcycle with no protection from rain and storms.  There are no overpasses or anything to hide underneath.  Your options are to hunker down by the side of the road or charge into the storm.  Which option is a better option?  At first, hurling yourself headlong into a storm may seem crazy.  After all, why would you volunteer for more than what is already where you are?  The answer is because the storm is coming.  You cannot avoid it.  Turning and driving in the other direction will only prolong your experience of the storm.

When you face the storm and push into it, you reduce the amount of time you’ll be in it.  As the storm moves across the ground, you move forward and find the end sooner.  With our loss and grief, we can turn the other way and attempt to run from it, or we can face it and move forward at whatever pace we can manage.  If we face the storm and move into it, we’ll find the storm is over sooner.  No one is going to like loss, but maybe we can find our way through it by Finding Meaning.

Book Review-The Pumpkin Plan

Who wants to know how to grow pumpkins?  The answer is a handful of people, but that’s not really what The Pumpkin Plan is about.  It’s about an approach to your business that follows the pattern of the $500-per-seed great pumpkin growers.  The book was a recommendation from an entrepreneurial friend who thought the fundamental premises were interesting.  I found the process to be problematic.  Normally, I’d not post a review like this one.  I want you to know what books are good and add value to your world.  I avoid criticizing them, because that’s not valuable to you or me – but this is different.

The Oversimplification Class

The reason I’m writing this book review is so we can use the book as a case study for the kinds of books that provide formulas and checklists that are your supposed paths to success.  There’s always an “and then the magic happens” step, even though it’s almost never called that.  It’s something that if you knew how to do it, you wouldn’t have been looking for a book to make things better in the first place.

Mike Michalowicz isn’t alone in writing books that claim to have the magic formula.  Don Miller in Building a StoryBrand and Marketing Made Simple has a simple formula for clarifying your message.  Clarifying your message is a good thing – and something I still need to work on.  However, reading Don’s work and even consulting with his certified consultants doesn’t solve the problem.  Of course, there are dozens of other books that can fit in this stack at some level: Duct Tape Marketing, Guerrilla Marketing, The New Rules of Marketing and PR, The Challenger Sale, Fascinate, Launch, Launch!, and Traction to name a few.

What’s special about The Pumpkin Plan is that it takes the simplification to a whole new level.  It’s simple: focus on only those things that are going to give you the biggest pumpkin – and weed out the rest.  Straightforward.  Simple.  But, importantly, it’s impossible.


Our ability to predict the future is awful.  Superforecasting, The Signal and the Noise, and Noise are all great at explaining the challenges.  However, it can be summed up by understanding the difference between a Fermi estimate and the Drake equation.  With a Fermi estimate, you take many known factors and you put them together for a larger prediction that’s generally reasonably accurate.  The Drake equation is designed to determine the number of observable intelligent life in the universe.  The problem with the Drake equation is that we don’t have reasonable answers to the factors and the result is you end up with either an infinite number of detectable intelligent life forms – or zero.  (Sometimes on this planet, I wonder if there’s intelligent life myself.)

So, the core concept in The Pumpkin Plan is – for many of us – difficult to figure out.  Over a decade ago, I wrote the very first version of The SharePoint Shepherd’s Guide.  The very first year, it was a dismal failure.  It didn’t cover my direct costs not to mention my indirect costs.  A year later, it was a phenomenal success.  The difference was an email marketing campaign.  That’s it.  The product didn’t change.  The market didn’t even change that much.  It was one thing that worked that made the whole thing fit together and start to generate a substantial amount of revenue.  Had I assessed the growth potential of The Shepherd’s Guide using Mike’s formula, I would have trashed it and the seven digits of income it has produced to date with almost no effort.

Are there reasons to focus?  Are there reasons to stop doing what isn’t working?  Yes.  However, I can look at dozens of other entrepreneurial books that give equally bad opposite advice.  They tell you that most entrepreneurs would have been successful if they had just stuck with it a bit longer.  They’re using a variation of the benevolent dolphin fallacy.  (See How We Know What Isn’t So.)


The real difficulty isn’t in nurturing the things that are going to bring you success (as you define it) but rather knowing which things to weed out and which to nurture.  The difficulty isn’t in doing – it’s in deciding.  Entrepreneurs are necessarily and perpetually short on data.  They live on hunches and minimize their risks as best they can while waiting on the rest of the information to come in.

Precision agriculture has started to make the data for farming more available.  Equipment, seed companies, and others in the agricultural business are looking to eke out just a bit more from everything – and they’re doing it but slowly.  They think in terms of growing seasons.  They look for what did and didn’t work over the last season and try to adjust make it just a bit better each year.  Complicated forecasting models and precision performance data yield only minor improvements from the land each year – but those compound and are worth it.

Following Mike’s analogy is making decisions on insufficient data to the extreme.  You’re just as likely to prune or weed out the winner as you are the loser.  In fact, when you consider how little of what we do really works, you’re probably more likely to weed it out, because you can’t see its hidden value.  Consider it from another perspective: Richard Hackman explains in Collaborative Intelligence that the best metrics are far-leading metrics that sometimes show negative short-term performance.

How do you know what to nurture when you can’t know what the real winners are?

Stock Markets

Mike says, “Don’t waste your time planting seeds that may or may not work out.  Plant the seed that you know has the very best chance of making it, and then focus your attention, money, time and other resources on that tight niche until all of your entrepreneurial dreams come true.”  Great – if you know with a degree of certainty what will work.  His advice is the financial advisor equivalent of picking the one stock that you put all your assets in.  No financial advisor would recommend that.  They’d lose their license.  What do you do that has more financial impact than the company that you’re running?

The answer for most entrepreneurs is that they pour their heart and soul into their companies, and often they neglect their retirement and other investments expecting that they’ll sell their company – “cash out.”  They tell themselves that they’re handling their requirement by building equity in the business.  Their only investment is their business, and Mike’s recommending against diversification.

Pick the Market

If you’re good at picking the market, then it could work, but it’s just as likely to lead to bankruptcy and starting over again.  Mike explains that he found markets and sub-markets that weren’t being served.  He went into them and was able to capitalize on the vacuum.  Good for him.  The number of entrepreneurs I’ve talked to will attribute success to just two factors:

  • Dumb Luck – At some point, if you play the lottery long enough, you’ll hit it big. Sure, you want better odds than the lottery, but at some level, you know that there’s only so much you can do.  You don’t and can’t have positive control of your success.  You can only hope to influence the right factors.  Louis Pasteur said, “chance [luck] favors the prepared.”  That’s all we can do: try to be prepared.
  • Surviving – Staying long enough to try the next thing and open the door for luck tomorrow.

I’m not arguing against improving your odds, trying new things, or learning.  I’m advocating an eyes wide open approach that makes sure that you’re not stuck with The Pumpkin Plan.

Book Review-Brief Cognitive-Behavioral Therapy for Suicide Prevention

There’s not much that works.  When it comes to suicide prevention, the list of interventions that reduce attempts is small.  There’s Brief Cognitive-Behavioral Therapy for Suicide Prevention (BCBT-SP), Dialectical Behavior Therapy (DBT), and Collaborative Assessment and Management of Suicidality (CAMS)BCBT-SP is a time-limited, targeted use of CBT, which has been widely validated for several concerns over the decades since its introduction.  It’s because it’s so widely adopted and widely known that it is so interesting to me.

Other Options

I should say that DBT, as the BCBT-SP book points out, is complicated and difficult to implement correctly.  It also tends to be resource intensive – as CBT can be.  That was my experience as I began studying it.  In addition, much as I found with NLP, everyone seems to define it a bit differently.  (See The Ultimate Introduction to NLP: How to Build a Successful Life for more.)  It’s still in my backlog for study, but it’s hard to bring myself to it.

CAMS is another option, which is more straightforward.  However, CAMS is intentionally designed for the mental health professional, and its training systems are geared towards that audience to the exclusion of non-professionals.  As a result, my research into CAMS was stopped before I started.

Direct or Indirect

The research is relatively clear.  When dealing with someone who is suicidal or potentially suicidal, the best path is direct.  Asking them if they’re considering suicide doesn’t make them more likely to attempt or die by suicide.  The clinical approaches that indirectly deal with suicide don’t work.  Despite this, many professionals don’t directly address the topic of suicide with their patients.  They instead work on skills they believe may be useful and dance around the topic.

There are likely two factors for this.  First, they probably don’t know the research.  Most mental health professionals don’t do that much work to keep current or to broaden their skills.  The reputation of the industry is not great, as The Heart and Soul of Change points out.  BCBT-SP explains that peer reviewed research points to “insufficient education and training for clinicians in newer and better models of care.”

Second, they’re probably, themselves, uncomfortable with the topic.  That makes it hard to have a conversation with patients.  If you can’t keep from being triggered by the conversation, you won’t be able to have it with a patient.


BCBT-SP focuses on the fluid vulnerability model, which has four factors: behavioral, cognitive, emotional, and physical.  They’re separated into two tiers: baseline and acute.  Each of us has a set of vulnerabilities for each of the four factors at baseline.  This is the place that we operate from most of the time.  We can have huge capacity and tolerance at our baseline – or not much at all.  An activating event triggers our acute factors.  When the sum total exceeds our threshold for tolerance, a suicidal episode may occur.  From the outside, it may seem like a relatively minor issue, but when processed by someone with a low tolerance, it may be more than they’re capable of.

The baseline tolerance comes from our experiences and our skills.  The adverse childhood experiences (ACEs) study connected health outcomes as an adult to the experiences as a child.  (See How Children Succeed for more on ACEs.)  Pushing back even further, fetal origins of adult disease (FOAD) indicates that the stress our mothers felt during our gestation may impact our health status decades later.  (See Why Zebras Don’t Get Ulcers for more on FOAD.)  What’s unstated in this research is that our mental health – our ability to develop coping skills – has a huge impact on our physical health.  Change or Die quotes Dr. Raphael “Ray” Levey that 80% of our medical costs are driven by five bad behaviors: too much smoking, too much drinking, too much eating, too much stress, too little exercise.

Matthieu Richard, in Happiness, recognizes that we can’t change the past or, in many cases, our circumstances, but what we can change is the way that we think about our circumstances.  We can change our reaction to the circumstances and thus our capacity to tolerate stress.

Richard Lazarus in Emotion and Adaptation explains that our emotions aren’t directly driven by the external world but are instead processed through our brains and filtered to what we’d express.  Daniel Kahneman calls this System 1 in Thinking, Fast and Slow.  We see patterns, apply meaning, and respond – very quickly.  What BCBT-SP does is help to change our processing of our circumstances so we can see them in a better light.

Interpersonal Psychological Theory of Suicide

It’s a simplification of Joiner’s work, Why People Die by Suicide, to condense the model to just desire and means – but it works.  For a suicide to happen, one needs both the desire and the means.  If you eliminate either, you have no suicide.  Given the nature of suicidal ideation being so unpredictable and fleeting, it’s probably no great surprise that restriction of means has a greater impact on suicide attempts and deaths than attempts to change the way that people process their circumstances.

The problem with means restriction is that nearly 50% of the suicides in the United States are done with a firearm, and the United States is in love with our firearms.  The Second Amendment to the Constitution is the right to bear arms.  The mechanisms you use to restrict someone’s access to a firearm are often treated with a high degree of skepticism and concern.  Luckily, the research supports that you don’t need to create a big barrier between the use of the gun and the person with suicidal ideation.  Like Adrian Slywotzky explains in Demand, sometimes a small barrier is all it takes to prevent a behavior.

Certainly, it’s best to remove the firearms from a suicidal person, but smaller measures, such as installing a gun lock – which prevents activation until removed – is enough.  Even separating the storage of ammunition and the storage of the gun itself has a non-trivial, positive impact on outcomes.

Other approaches, like some of those that Thomas Joiner shares in Myths About Suicide are also useful.  95% of people who were stopped trying to jump off the Golden Gate Bridge never died by suicide.  Suicide fences on bridges (making it harder to jump) are also effective.  It turns out that people don’t often change their chosen method of suicidal attempt.  It seems like they just decide if they can’t die the way they want (gaining some control over death), they’ll just keep living.  (See Ronald Maris’ Comprehensive Textbook of Suicidology for more on control over death.)

Escape the Hopelessness

Whether you subscribe to Edward Shneidman’s beliefs that it’s psychache – psychic, psychological, or emotional pain – that causes people to die by suicide or something else, the sense that suicide is sometimes an escape can’t be ignored.  If you believe that life is unbearable and won’t get better, then suicide begins to be seen as a reasonable answer.  When all other paths towards resolving the problems of life, are blocked then removing life seems reasonable.

Perhaps then part of the answer towards reducing suicide is the process of reducing hopelessness and the belief that suicide is a better option than any of the other options available – or even an option worthy of serious consideration.  Seligman and his colleagues first started writing about learned helplessness, the animal equivalent of hopelessness, in the 1960s.  They realized the powerful problems that becoming helpless – or hopeless – creates.  Decades of research has continued along these lines, and Seligman explains in The Hope Circuit that they got it wrong.  It wasn’t learned helplessness but, as a colleague of his Steven Maier showed, a failure to learn control or influence that caused the subjects to stop trying.

Negative Emotions

“Afflictive emotions” is the way that the Dali Lama describes them.  They’re emotions that take away from a person.  Strangely, what we call an “emotion” in English might have different words in Tibetan or at least more nuanced connotations than we typically observe in English.  For instance, pride in oneself might be bad, but pride in what others have accomplished can be good.

Anger might be an easy target for negative emotions – but it’s not necessarily an afflictive or negative emotion.  Aristotle believed that being angry with the right person to the right degree and for the right purpose was difficult – but when done to these standards, it’s not a negative emotion.

However, there are some emotions that are negative.  Humiliation, for instance, is universally bad.  There’s no need to humiliate others – or to feel humiliated yourself.  Other emotions, like guilt and shame, may be adaptive, but they’re still negative and can easily be overdone.  Guilt is that you’ve done something wrong.  Shame is that you are bad.  (See I Thought It Was Just Me (But It Isn’t) for more on shame and guilt.)

These emotions may have an evolutionary advantage – teaching us what we should or shouldn’t do.  (See The Righteous Mind, The Blank Slate and The Evolution of Cooperation for more.)  The challenge is that these emotions are amplified in those who are depressed and can overwhelm them.

Listened To

In healthcare and in life, there are many forms to be filled out and an array of people who are looking to help you fill out the forms you’re expected to fill out yourself and those they’re expected to fill out.  They’re systems designed to ensure that people are treated well.  It’s common to use a PHQ-2 followed by a PHQ-9 if the answers on the PHQ-2 are concerning.  It’s a series of checks and answers – but often it seems like that’s all it is.

The questions are asked by others with leading language and guiding glances.  They don’t want you to answer in a way that triggers the second set of questions – and even if you do, they’re not interested in the truth.  They’re interested in checking the right boxes so they can go on with their next task.  It’s no wonder that people don’t feel listened to.  How can you feel authentically listened to when the entire interaction is about filling out the forms?

That’s why, when people go through the BCBT-SP process, they often remark that the process is the first time they’ve ever felt listened to.  The first step in the process is to have the person tell their story in their words as a narrative – not as answers to standard questions on a form.

White-Knuckling It

One of the oddities that we observe in suicide is that attempts go up at the end of a depressive episode.  Some account for this by saying that the psychomotor retardation (lack of desire to do anything) that depression brings abates (goes away) prior to the desire to die disappearing.  Another odd experience is the increase in attempts as people leave an inpatient treatment facility.  They seem to be getting better – but that turns out to not necessarily be the case.

One reason for the appearances not matching the outcomes could be that people are “white-knuckling it.”  That is, they’re summoning all of their willpower to push back the depression and suicidal ideation.  That can work for a while until they’ve exhausted their willpower.  Roy Baumeister explains in Willpower that it’s an exhaustible resource – just like our muscles.  So it can be that they seem better as they’re consuming willpower and fall when they exhaust it – sometimes falling into a pit of despair that leads to a suicide attempt.

Neither you nor those you care about should have to white-knuckle it.  Brief Cognitive Behavioral Therapy for Suicide Prevention is an alternative – that works.

Book Review-Against Empathy: The Case for Rational Compassion

Who could be against empathy?  Isn’t it a good thing?  Don’t we need it to relate to one another?  How could someone, Paul Bloom, write a whole book about why empathy is bad?  The answer is a surprising journey into what we mean when we say “empathy” and the negative side of what is seen as a wholly good response.  In Against Empathy: The Case for Rational Compassion, Bloom decomposes what we mean when we say “empathy” and suggests that we should focus on only the “good” parts of empathy while finding ways to side-step the problems.

Cognitive and Affective

A good place to start is the fact that we use empathy to mean two relatively distinct things.  The best definition of empathy that I’ve seen is “I understand this about you.”  It’s a simple expression that equates empathy with understanding.  When I’m understanding, I can mean that I understand, cognitively, what your world is like.  I understand the environment, the factors, and the connections to other people.  To understand affect is to understand how the other person feels.  That’s really what most people mean when they say that they have empathy for someone else.  They’re presuming that they can feel what the other person is feeling.

The Grief Recovery Handbook makes a point of saying that no one else can know exactly how you feel.  How Emotions Are Made speaks about how emotions are constructed from the experiences we have in the moment, in the past, and our processing of those experiences.  So, while we generally mean that we know what someone else is feeling when we say “empathy,” it’s probably more accurate to say that we can approximate someone else’s feelings rather than “knowing” them.

The Affective Problem

Fundraisers who are looking to get you to part with your hard-earned money to support a need in a far-flung land know that you’re much more likely to support a single person – particularly a needy child – than you are to write a check to support a city, a nation, or a cause.  Organizations have long since learned that a name and a picture together are substantially more likely to pull you in to get you to donate than a picture without a name – or a name without a picture.  In these cases, affective empathy may be good, but what happens when it’s a zero-sum game?

Consider that you’re told that there’s a waiting list of patients for a doctor.  They’re carefully prioritized so that the neediest children are seen first.  You’re given the profile of one little girl who needs help, but her name is way down the list.  You’ve got the opportunity to move her up on the list.  Will you?  When focusing on how she feels, her world, and her plight, many do move her up in the line.  However, this is a place where empathy works against us.

If you trust the algorithm the doctor uses to prioritize cases, moving this case up pushes down other needier cases.  In short, you’ve done a net harm by prioritizing this one case.  Your empathy has sensitized you to the one case but has blinded you to the larger implications of your decision – and this is the key challenge with affective empathy.  It blinds us.

Cognitive Distortions

Bonds That Make Us Free, The Anatomy of Peace, and Leadership and Self-Deception all point to the challenges that an emotionally activated brain brings.  We learn that our emotions often take control – and won’t let rationality get a word in edge-wise.  In Kahneman’s language in Thinking, Fast and Slow, it’s System 1 overriding System 2.  In the language of Jonathan Haidt in The Happiness Hypothesis, it’s the emotional elephant taking the rational rider where the elephant wants to go.  The truth is that our emotions have more control than we’d like to admit, and engaging them necessarily allows us to be influenced by our biases – which isn’t a good thing.

In the case of the girl, it blinds us to the tragedy of commons.  The tragedy of commons is a well-known parable about how individually rational decisions can be destructive to the whole.  The idea is that a town allows the residents to have their livestock graze on the town commons for free.  It is therefore in every resident’s personal best interest to have as much livestock as possible grazing on the commons.  However, when this is done collectively, the commons will be over-consumed and eventually no plants will be available for anyone’s livestock.  Rational decisions made by individuals about a common resource will eventually destroy the whole.  The girl’s case is a different form where to improve her treatment we must reduce others’ treatment.

Trigger Warning

If we’re encouraging affective empathy, we’re necessarily encouraging people to become triggered by other’s emotions.  This is the very thing that The Coddling of the American Mind warns us about.  When we’re worried about triggering other people, we become tentative, and our students and friends stop trying to understand other perspectives, because to do so may make them uncomfortable.  Instead of challenging ourselves to see and understand the world better, we shrink back into a place of safety.

Walter Michel’s Marshmallow Test may seem like a far cry away from trigger warnings – but the distance is much smaller than people realize.  The marshmallow test was about allowing discomfort in the short term for long-term reward.  Those who are focused on the need for trigger warnings are worried about their here-and-now feelings at the expense of their ability to cope with discomfort in the future.  Albert Bandura explains that desensitization to stimuli is an important technique in reducing phobias – and maladaptive responses of any kind.  In Moral Disengagement, he explains how people don’t want to accept responsibility for their part in larger amoral actions but instead become desensitized – either for better or for worse.

Weighing Now and Then

Ultimately, empathy in its focus on the here and now, blinds us – or partially blinds us – to the future impacts.  We’ll take the marshmallow now, because we don’t know about tomorrow.  We’ll buy on credit today, because the future is something vague that may never happen.  Both Daniel Pink in When and Phillip Zimbardo in The Time Paradox have addressed how humans perceive time – and it’s not second-by-second.  Instead, we tend to unequally weight the past, present, and the future.

Empathy, by the nature of the present focus, causes us to insufficiently consider the costs in the future.  To be clear, it’s not that being in the present moment is bad – it isn’t.  However, when we can’t evaluate the future consequences to our present actions and experiences, we’re failing our future selves and the conditions they’ll find themselves in.

Capacity and Propensity

There’s a challenge.  Empathy has a positive side but also the potential to be used for evil.  It’s empathy that allows cult leaders to drive followers to kill themselves and their children.  Just as it can be used as a powerful force for good, it can be used by evildoers to manipulate and trap victims.  This raises the question about how someone can feel what someone else is feeling and inflict harm.  The answer seems to come in the form of the difference between capacity – the ability – and the propensity – the willingness to do so.  It can be that people who use their capacity for empathy for evil may turn off this capacity while they’re harming the other person.

This ability to turn off – or turn down – empathy may be something that parents need to be able to discipline their children.  In The Psychology of Not Holding Children Accountable, I walk through all the ways that parents can be sucked into not holding children accountable, most of which are an inability to separate their child’s immediate pain from their own discomfort.


No one wants favoritism – unless the other person is favoring them.  We want our friends and family to favor us more than they might the random person on the street.  So, it’s more accurate to say that we don’t want others favored over us.  Empathy creates a favoritism for those that we’re feeling empathy for.  Favoritism in the animal kingdom isn’t absent.

Chimpanzees are more likely to survive to adulthood if their mothers are more social and supportive of other mothers.  It’s the kind of old-time social network that Robert Putnam talks about in Our Kids.  It’s where everyone looked out for everyone else.  Except that it’s not really everyone.  It’s those people who are in a network of commitments with you.  In an old book, Understanding Computers and Cognition, Terry Winograd and Robert Flores describe organizations as a network of commitments – societies, families, and friend groups fit the same model.

Backup Enforcement Force

To maintain social order, we need more than just the kind of trust that Francis Fukuyama describes in his book, Trust: Human Nature and the Reconstitution of Social Order.  Trust does bind us together and enable us to be more collectively effective, but we need to accept that we need some sort of backup enforcement force to ensure that the rules of social order are maintained.  Rushworth Kidder separates moral and ethical problems based in part on societal conventions in his book, How Good People Make Tough Choices.

However, even the most generous thinkers about human nature recognize the need to have a mechanism for enforcing the social norms.  Jonathan Haidt in The Blank Slate and Robert Axelrod in The Evolution of Cooperation arrive at the same conclusion from two different approaches.  We need to be able to enforce the standards of behavior we hold – and that may mean hurting someone’s feelings or even hurting them.

However, it won’t hurt to consider whether you should be Against Empathy.

Book Review-The Noonday Demon: An Atlas of Depression

If you’re going to be navigating something, it’s helpful to have a map – or even multiple maps.  For navigating depression, Andrew Solomon gives us The Noonday Demon: An Atlas of Depression.  A depression sufferer himself, he walks us through his personal experience, the experiences of those he interviewed, as well as a selection of the research on the topic of depression.  At times, the experiences and research appear to differ.  Even two people’s stories seem to point to different ways of experiencing depression.  In the end, Solomon exposes that what we call depression may be a cluster of similar maladies with a variety of factors leading towards them.

What is Depression?

It’s a good place to start.  Defining what depression is – and isn’t.  Of course, the DSM-5 has a definition for a major depressive disorder.  However, for most, including psychologists, this definition fails to capture the state well.  It leaves lots of gray areas between what’s “normal” and what’s “abnormal.”  Solomon describes depression as a flaw in love.  “To be creatures who love, we must be creatures who can despair at what we lose, and depression is the mechanism of that despair.”  He clarifies later, “Grief is depression in proportion to circumstance; depression is grief out of proportion to circumstance.”

Herein lies the rub of depression: assessing the circumstances.  We’ve learned that some of the best ways to combat depression don’t change the circumstances.  We find that the best treatments for depression change the way we view the same circumstances.  What’s proportional to one may not be proportional to another.

Later he admits, “Depression? It’s like trying to come up with clinical parameters for hunger, which affects us all several times a day, but which in its extreme version is a tragedy that kills its victims.”  We can map out the extremes of hunger – malnutrition – and the extremes of depression – major depressive disorder – but separating the normal from the abnormal or the proportional from the non-proportional is much, much harder.

The Impact

Depression is bad in that it prevents people from feeling good.  One of the preeminent markers is an inability to experience happiness or joy (anhedonia).  However, what’s the real impact of depression beyond the loss of happiness and joy?  It’s the leading cause of disability for persons in the United States over the age of five.  Fifteen percent of people who are depressed will eventually die by suicide – compared to 14.5 per 100,000 overall.  (Thus, this is 1,000 times increase in probability of suicide).

The How of Happiness quotes the World Health Organization as believing that depression will be the second leading cause of mortality and impacting 30% of all adults by 2020.  (Obviously, this was prior to 2020.)  Some place the estimated impact of depression through lost work and treatment at over $200 billion dollars annually.  It has a real impact on economies across the globe.

The Cause – Biology?

With the advent of selective serotonin reuptake inhibitors (SSRIs), it seems like depression might be caused by a lack of enough serotonin in the brain.  Supplements seek to increase the levels of 5-hydroxytryptophan (5-HTP), a key precursor to serotonin.  There is some research that shows that these have impacts.  However, some are still appropriately concerned and critical of the impact of changing brain chemistry, including William Glassier in Warning: Psychiatry May Be Hazardous to Your Health.

Work continues to find genetic markers that lead to depression.  Research seeks to separate genetics from environment in an effort to focus on the key factors that lead to depression.  Meanwhile, we’ve begun to discover that genes don’t work on their own.  In The How of Happiness, Sonja Lyubornsky explains that roughly 50% of our happiness comes from a genetic “set point.”  This is consistent with others, including Judith Rich Harris, who explains that our children’s behavior may be similarly influenced by genetics at a level of about 50% in her books No Two Alike and The Nurture Assumption.  In short, biology is not destiny.  Certainly, we see genetic factors in everything, but we are beginning to realize that many of our genes require activation from the environment.

The Cause – Environment?

It was a landmark study.  It coded childhood experiences – adverse childhood experiences – and tallied them.  The results were striking.  Those adults whose childhood was wrought with more adverse experiences had worse health.  In How Children Succeed, Paul Tough explains that the higher the score, the worse the outcomes.  However, that’s not the end of the story.  The trauma that leads to poorer health can precede birth.

In Why Zebras Don’t Get Ulcers, Robert Sapolsky highlights the work of David Barker, who was able to show that long-term health could be impacted by the stresses that a mother felt during pregnancy.  His research seemed to indicate that if the mother was stressed, the child would be predisposed to perceiving the world as stressful rather than safe.

Other research seems to indicate that if we constantly trigger the hypothalamic-pituitary-adrenal (HPA) axis, which is our response to stress, it may get stuck “on.”  In other words, exposure to stress can make us more likely to see stressful things – even when they don’t exist.  This is somewhat mediated by Richard Lazarus’ work as chronicled in Emotion and Adaptation.  (Lisa Feldmen Barrett in How Emotions Are Made expresses similar experiences).  The point of Lazarus’ work is that we see stressors and then we evaluate the stressor in comparison to the possible outcomes, their probability, and the impact.  This is divided by our capacity to cope.  The result is the degree to which we’ll feel stress in the situation.  Even in stress the way that we think about it – our controllable cognition – plays a huge role.  It may not eliminate the stressor, but it can change the impact it has on us.

Perhaps depression isn’t about our genetics – or our environment – but rather is some interaction between the genetics, our environment, and how we perceive it.

Relating to PTSD and Post Traumatic Growth

Post-traumatic stress disorder (PTSD) is fairly-well known now.  However, the function isn’t as well understood.  PTSD comes from a traumatic experience that an individual has been unable to fully process.  PTSD is subjective.  What is traumatic and cannot be processed by one might be processed by someone else just fine.  It’s not a failing, it’s a mismatch between the developed skills and the perception of the events.  The secret to PTSD recovery is helping the person learn how to process their experience more completely.

Post-traumatic growth (PTG) is another option for situations where trauma has occurred.  It’s processed, and the person is changed, for the better, as a result of having gone through the trauma.  It doesn’t mean that they’d want to incur the trauma again or that it was pleasant, just that they’ve found a way to become better through it.

Solomon explains depression in this way for him.  He’s found that he’s grown through his experiences with depression, no matter how much he may have wished not to have had to suffer.


When I reviewed Loneliness, I shared the dance that loneliness and depression are in.  Solomon agrees.  He sees depression as causing loneliness and vice versa.  Those in depression find themselves separated from others by an invisible wall.  They can see that there are others around, but at the same time, they feel separate and apart.  When you find loneliness, look, and you’ll find depression.  Where you find depression, look, and you’ll find loneliness.


As a goal, perfect isn’t bad.  It’s perfection that Anders Ericsson and Robert Pool were talking about in Peak: purposeful practice in the pursuit of perfection.  The problem is what Barry Swartz in The Paradox of Choice explains drives people to be less happy.  Maximizers – those who must have perfection – are less happy than those who are more likely to satisfice – settle for “good enough.”  We all have some times when we maximize, we’ve got to have it perfect.  The trick is that when we expect we must be perfect, we will invariably fall short, so we’ll be disappointed in our performance, and that is one step away from depression.

Burnout and Depression

It’s time for a slight side-step from Solomon’s work to explain an important relationship between burnout and depression.  Research shows that burnout screening is an early indicator for future depression.  They’re not fundamentally different – but they’re different.  Both are driven by feelings of inefficacy.  The difference with depression is a sense of futility.  In short, “What does it matter?”  This is not something that we typically see with burnout but is present when people are depressed.  (For more burnout/depression resources, see everything that we’ve got available at – almost all of which is completely free.)

Like most things in mental health, there are probably those who are burned out who are wondering about the futility of it all, and those who are depressed who understand the meaning of life.  However, as a general rule, a quick way to separate the two is futility.


At the heart of both burnout and depression is a sense of hopelessness – that it can’t get better.  It will never be any better than the current moment.  The situation is permanent.  It’s pervasive throughout someone’s life, not just the current situation.  It’s also personal.  It’s not caused by other factors, it’s a result of the person that someone is.  The problem is that these views aren’t right.  (See The Resilience Factor for more.)  The problem is that things do change, it’s not permanent.  No situation is universally pervasive, and it’s rarely as personal as we believe.

C. Rick Snyder in The Psychology of Hope explains that hope isn’t a feeling, it’s a cognitive process made of waypower – knowing how – and willpower – desire or commitment. (For more on willpower, see Willpower.) When we see people who are hopeless, we often find they don’t know “how” things could get better.  Some degree of cognitive constriction may lead people to overlook the ways that things may get better on their own, what they may be able to do to make it better, or simply how the situation can be changed.  It’s this same cognitive constriction that can lead to suicide, as The Suicidal Mind points out.

Suicide by HIV

Solomon admits that his intent was to die via AIDS.  He was trying to commit suicide but in a way that made it seem not like suicide.  This is at the heart of the challenge with identifying suicidal behavior.  Inferring intent – when someone doesn’t write a book about it – is hard.  (Only ~1/4 of people even write suicide notes; the odds of writing a book on depression are substantially smaller.)  In some cases, intent is clear, but in many others – like Solomon’s attempt – intent is very unclear.  (See Suicide: Understanding and Responding for more.)

We don’t track statistics – even if we could confer intent – on rare forms of suicide.  Instead, we must realize that there are many, many ways to kill oneself if someone wants to – and it makes stopping someone from committing suicide very difficult.  (See Suicide: Inside and Out for more on how difficult suicide can be to prevent.)

Weakness of Character

Depression, suicide attempts, and mental health issues are often seen not as illnesses but rather weakness of character.  It’s as if others believe that what’s lacking is willpower – not that there’s something wrong for which someone can’t be held accountable.  In Willpower, Roy Baumeister explains that it’s an exhaustible resource – something that everyone has limits on.  The introduction of SSRIs may have strengthened the medical model for depression, but as we saw above, it’s not enough, and people know it.

Never has someone said that it’s a weakness of bone when someone walked in with their arm flapping after a break.  We don’t call people weak-hearted as they’re having a heart attack.  Yet somehow, we believe that we should be able to control our mental health in ways that we can’t manage our physical health.  It’s been a long time since we believed that illness was a plague brought upon us by God.  Instead, we follow a biological germ theory of disease that says we were infected – not that God is inflicting suffering on us through physical illness.

There’s a serious schism of accountability and responsibility for mental health when compared to physical health.  In short, we don’t give people who struggle with mental health a fair shake.

Low Side Effects

Treatment with SSRIs isn’t because of their overwhelming efficacy.  They have low double-digit margins of efficacy over a placebo.  Solomon makes the valid point that they do help some – but that doesn’t excuse dispensing them via a PEZ dispenser.  We prescribe SSRIs with very little concern – in part because they have a relatively low side-effect profile.  Sure, there are sexual dysfunction concerns, but 99% of people with acute major depression report sexual dysfunction anyway.

At some level, SSRIs and other potentially addictive drugs are something to try.  If you can’t mitigate the pain, you’ll have trouble getting to a point where anything else will help.  Often, a pill is quick and easy.  Treatments like ECT (Electro Convulsive Therapy) and its newer cousins offer quick relief but there are still some concerns about side effects.  Talk therapy, including cognitive behavioral therapy (CBT), have been shown to be effective – but they take a long time.  In many ways, SSRIs and other medications are “the easy button.”

Substance Abuse

Chasing the Scream and The Globalization of Addiction do a good job at fighting back the pharmacological theory of addiction – that is, the substances make you do it.  Growing up in the 1980s, I was told that just one hit could start an addiction.  Nancy Regan told us to “Just Say No” to drugs – and it didn’t work.  The uncomfortable truth – for everyone – is that substance abuse is a solution to a different problem.  It’s quite obviously a bad solution – but it’s a solution nonetheless.  Something that started out as a coping mechanism to numb or distract from pain in someone’s life gradually took control of them until they could no longer stop.  Solomon says, “Every addict had a honeymoon, during which they could control their use.”  In short, it was a coping mechanism, but eventually the coping mechanism took control.

Depression and substance use disorder (SUD) – which is the preferred terminology now – are related.  When you’re depressed, you’ve got a part of your life you want to numb, and substances do that.  When it’s become an addiction, you start to lose connections with others, financial resources, stability, and sometimes even dignity.  That triggers depression.  They feed each other until they’re stopped.

Another view is that substance abuse is the substitution of a “comfortable and comprehensible pain” – the consequences of the addiction – for an “uncomfortable and incomprehensible pain.”  The uncomfortable and incomprehensible pain may not even be conscious.  It may be something that we’ve never been equipped to find or deal with.  If the substance takes away the pain from that, then it seems like its pains are a good bargain.

Time of Decide

One of the most effective interventions for suicide prevention is restriction to means.  (See Rethinking Suicide for more.)  People won’t often change their tool of choice from guns to drugs to bridges.  When you prevent access, you often prevent death.  We see it in suicide fences on bridges – which prevent people from jumping to their death.  We see it when gun locks are introduced into a population.  We see it wherever we work to block an avenue of death.

Seen differently, thoughts of suicide and the cognitive constriction that comes with it are often fleeting.  One moment, suicide seems like the only option, and the next moment, you’re left wondering how you could have possibly thought that – that is, of course, if you didn’t have access to the means you needed to carry the thought out.

When we’re considering how to decrease suicide, delaying is our friend.  Knowing that you don’t have to decide right this moment whether you want to die by suicide – you can defer that decision until later – may be helpful.  It’s not ideal.  We want people to cross it off the list of possible options – but for some people, that it is not possible or realistic.

Suicide and the Survivors of Concentration Camps

Victor Frankl wrote Man’s Search for Meaning as a way of chronicling the conditions of concentration camps but more importantly, to give hope that even in the worst of conditions humanity perseveres.  The problem is that too many of those rescued from concentration camps would later come to die by suicide.  The specific reasons aren’t clear.

Maybe they survived the camp only to have taken on too much mental anguish to continue forward on their own.  Maybe their hopes that their loved ones were still alive were dashed when they were freed, and they no longer felt as if they had anything to live for.

Whatever the reason, those who walked or rode out of the camps didn’t seem to have the tools they needed to free themselves from the memory of the camps and the tragedies they were forced to live among.

Proactive vs. Reactive

One of the challenges with depression, like all of healthcare, is that we often look towards solving things once they’ve become problems.  We don’t look for ways to prevent problems from occurring in the first place.  The old saying is “A stitch in time saves nine.”  Yet, we continue to battle depression and suicidal ideation after it’s formed rather than looking for ways to create mental health – rather than avoiding mental illness.  If we can be proactive, we’ll spend less – but that takes time and isn’t always in the politicians’ best reelection interests.

Mental Illness, the Family Secret Everyone Has

The thing is that every family has mental illness somewhere.  We ignore it, avoid it, and dare not discuss it, because it’s somehow shameful.  It’s sort of like passing gas – everyone does it, but no one wants to admit it.  The net effect is that we push mental health into the shadows and only want to address it when we see the next mass shooting.  We address mental health when it becomes visible, and someone demands that we put an end to the tragedies that those with untreated mental illnesses inflict on others – but by then, it’s too late.


One of the most overlooked and undervalued aspects of our human existence is the need for good, quality sleep.  It’s the brain’s way of rejuvenating, cleaning, and processing the day, yet we’re chronically sleep deprived.  We’re constantly trying to shave off a few minutes of sleep to get one more thing done – but in the process we’re making ourselves more depressed, more likely to attempt suicide, and generally miserable.  Prioritizing sleep is one thing that we can all do to reduce depression – and too few of us can make this a priority.

The opposite of depression is life.  Maybe you can find your way by studying the maps in The Noonday Demon.

Book Review-The Disruption Mindset: Why Some Organizations Transform While Others Fail

Disruption isn’t the goal.  Growth and success are.  However, the path to growth often leads through disruption.  Charlene Li explains in The Disruption Mindset: Why Some Organizations Transform While Others Fail how to navigate the disruption and even encourage the right disruption to lead to the desired exponential growth.

Anyone can be disruptive; it takes a powerful person to be the right kind of disruptive at the right time to achieve the exponential results which investors often expect – whether you’re a startup or a large organization.

Unmet Needs

The fuel that drives disruption is the willingness to find and address the unmet needs of the customer.  Whether you’re disrupting the home movie business like Netflix or you’re a wireless carrier trying to capture new subscribers like T-Mobile, you’ve got to find the needs the customer has that you can meet and your competitors can’t.  If you do it right, you can leapfrog the competition.

There are lots of ways that people pursue understanding the unmet customer needs.  For instance, Business Model Generation proposes a business model canvas.  Clayton Christensen in Competing Against Luck proposes a model of jobs to be done.  Tom Kelley’s The Art of Innovation proposes a human-centered design process that is also a discovery process.

My experience is that this process of discovering the unmet needs of the customer is the most prone to error and ultimately failure.  Time and time again, I’ve seen technology companies propose that they know what the customer’s needs are only to discover that they didn’t really understand the problems – but no one else in the process could see the failure to fully understand before it became a problem.  The future planners, focus group leaders, researchers, and marketers weren’t able to make a coherent picture from the signals they were receiving, and as a result, they made something up that they thought would be “cool” or interesting, and no one else realized that it was fiction until way too late.

Make a Manifesto

If you’re going to disrupt an organization, you need a rallying cry.  You need something that people can get behind.  There’s a shared delusion that many corporate leaders subscribe to.  They believe they can control a disruption or transformation.  They believe it’s possible to architect, design, and deploy a plan that’s so perfect that it will fit every member of the organization in every situation.  Since the Agile Manifesto, we’ve realized that this isn’t truth, but it’s comforting to believe that we’re in control.  (See Compelled to Control for more about the illusion of control.)  Li suggests that anyone can write a manifesto to inspire the disruption that the organization wants and needs.  It has these components:

  • Start with a rant
  • Flip the rant into a belief
  • Add what you are going to do to act on that belief
  • Use a collective and active voice
  • Write a blog post about each statement
  • Test with customers
  • Keep it to a page

The key is to help everyone believe that the leader isn’t thinking about the disruption alone.  They’ve got an inclusive approach where everyone will benefit from the changes.  In Li’s words, “leadership is a mindset, not a title.”  Joseph Rost in Leadership for the Twenty-First Century agrees.  He even goes further to say that it’s a relationship towards the end of meaningful change.  In short, you can’t be a leader if you don’t intend to change – and improve – with others.

Consensus and Trust

Many organizations have fallen into the trap that they need consensus.  Thomas and Kilmann created a conflict mode instrument that places five options: avoiding, accommodating, competing, collaborating, and compromising on two dimensions: assertive and cooperative.  The interesting aspect of their instrument is that the best answer isn’t in the upper-right corner, as one might expect.  Collaborating to the extreme is consensus.  Their model (and research) focuses on the best answer as compromising.  They don’t mean it in a pejorative way; instead, it’s a recognition that consensus-driven approaches often take too long.  Sometimes, we have to just trust others even when we can’t defend the decision.

We see this echoed in the work of Patrick Lencioni in The Advantage, in Crucial Conversations, and in William Issacs’ work, Dialogue.  Consensus can take too long.  We need to build and reinforce trust when we can so that we can lean on it when it’s necessary to move faster than a consensus-based approach would allow.  (See Trust => Vulnerability => Intimacy, Revisited for more.)

Cultivating Constructive Criticism

Some cultures invite constructive criticism.  Some even require it.  On the outside, the cultures may seem harsh.  In Radical Candor, Kim Scott explains that “it’s not cruel, it’s clear” when speaking directly to other people.  Cultivating these conversations requires work.  It’s a step beyond the psychological safety that Amy Edmondson proposes in The Fearless Organization.  It’s imperative to share concerns and to speak up.  Back in 1977, Irving Janis and Leon Mann first wrote about “groupthink” and the challenges that occur in groups in their book Decision Making.  Since then, Richard Hackman revisited the challenges of sharing the truth in Collaborative Intelligence.  They recommend that someone be assigned the role of the devil’s advocate – that is, someone should be tasked (temporarily) with trying to poke holes in the proposed direction.  Even John F. Kennedy took this approach with the Cuban Missile Crisis after the fiasco that was the Bay of Pigs invasion.  In One Minute to Midnight, there are details about how dissent wasn’t a problem, it was required.

Dave Snowden, of Cynefin fame, describes this process as ritualized dissent, something that he often teaches at workshops.  By making it an explicit part of the process, it’s often possible to avoid someone being singled out as the naysayer.

Structure and Lore

Organizational charts and organizational structure aren’t something new or interesting to anyone involved in a corporation.  The tree-view charts, with who reports to whom, have been a part of the corporate landscape for decades.  Structure is part and parcel for corporate life.

Organizational policies, procedures, and processes are common as well as everything that can be done can be turned into a collection of policies, procedures, and processes.  It’s standard corporate fare – that startups often sidestep in the interest of expediency.  However, there’s another component that’s important to organizational health: the lore.

Li describes organizational structure as the spine, process the lifeblood, and lore as the soul of organizational culture.  Lore are the stories that are told.  They can be the origin stories – stories that are about how the organization was formed or transformed.  These stories form employee opinions about how the organization is to behave.  They’re stories of heroic customer service.  They’re stories of how the organization treats employees.

If you want to radically disrupt the culture of an organization, you need the stories to be different.  It means replacing the stories that no longer match the desired culture and supplementing the stories in places where the culture won’t grow as you desire it to.  While this can be tricky, confusing work, it’s work that needs to be done if you want to change the hearts and not just the minds of everyone involved.

To make the kinds of changes that our world needs today, you may just find that it takes The Disruption Mindset.

Book Review-Uncaring: How the Culture of Medicine Kills Doctors and Patients

It is not that they set out to be uncaring.  Quite the opposite.  Doctors, most of them anyway, got into medicine because of their concern for others.  That’s what makes the fact that modern medicine, particularly in the United States, isn’t as good as it could or even should be for patients or doctors.  In Uncaring: How the Culture of Medicine Kills Doctors and Patients, Robert Pearl pulls back the covers on the systems that drive our modern healthcare industry and what’s wrong with them.

I’ve read and reviewed Pearl’s previous work, Mistreated, and have fallen into the awareness that he and I can correspond from time to time on the problems with healthcare and the associated public health issues.  I deeply respect Pearl’s perspective and wisdom about how the systems work – and how they don’t.  Uncaring is no exception to this general regard I have for his work – it provides a clarity into what ails the system – even if he cannot offer any specific remedies.

The Long History of Bad Practices

It was Ignas Semmelweis who is credited with the beginnings of our awareness that would ultimately become germ theory.  What’s not commonly known is that Semmelweis was dismissed and nearly unemployable.  He died alone in a mental institution.  So much for the embrace of new and improved techniques to move forward the practice of medicine.  Unfortunately, his experience was far from unique.

The process of bloodletting involves removing blood from an infected individual with the thought that the four humors are out of balance.  It’s believed that this killed George Washington – yes, that one.  Of course, he was already suffering from some ailment, but the degree of blood loss due to the bloodletting could not have helped.  And still, bloodletting remained an acceptable medical practice even through 1923, when it became a published practice.  This is nearly 100 years after the harmful effects were established.

What’s important here isn’t that there were practices in medicine that were ultimately discovered to be harmful – there’s a long list of them.  The point is really the time between when a practice is determined to be bad and the time it takes for that information to permeate the practice.  Pearl cites the often-mentioned statistic that the average time for a medical innovation to reach practice today is 17 years – this is, I suppose, better than our history, but a far cry from what we can and should do.

What You See Is All There Is

Daniel Kahneman in Thinking, Fast and Slow describes it as What You See Is All There Is (WYSIATI).  Pearl describes it as a cultural insistence that doctors must follow their instincts in their practice rather than the data.  From the very beginning, they’ve been taught that they’re special, and it’s their powers of observation that save patients.  However, the problem is the data doesn’t support this conclusion.

Atul Gawande proposed bringing checklists to the operating room in The Checklist Manifesto.  This was in part to neutralize the power dynamics of the operating room so that staff could speak up, but in another way, it was the application of a proven practice to medicine that has struggled with reliability.  Gawande’s book was published in 2009, and to my anecdotal knowledge most operating rooms do not use checklists – and some that do use them do in a rather perfunctory way.

The data can tell you whether something works or not – if people are willing to look at the data.  Ivermectin, a veterinary anti-parasitical, was recommended by some as a solution to improving outcomes for those with COVID-19 – except it’s wrong.  There’s no data.  What people said is that 100% of the people they treated with Ivermectin got better.

The problem with this thinking is that it ignores base-rate.  The base rate of mortality – and even hospitalization – with infections from SARS-CoV-2 is relatively low.  (I’m not going to quote them here because the rates keep changing with each new variant.)  The highest probability for a small clinic that treats as few hundred patients is that all their infections will get better – working treatment or not.  Similar arguments were made about former President Trump’s suggestion that hydroxychloroquine sulfate (HCQ) and chloroquine phosphate (CQ) would be effective at improving COVID-19 outcomes.  These anti-malarial drugs were proven ineffective – but not before many people tried them – many of whom were written prescriptions by their family physicians.  (Ivermectin wasn’t approved for human use, so it wasn’t the physicians enabling this behavior, even if they were encouraging it.)

The problem is that, when there’s a low base rate of mortality, if you try something – and no one dies – you assume it was effective when it wasn’t.  Similar problems happen when people start thinking about surgeons.

Practice Makes Perfect

Anders Ericsson and Robert Pool explain in Peak that the best in every world of performance get better by purposeful practice.  Whether you simplify this to 10,000 hours, as Malcolm Gladwell does in Outliers, the point is that more purposeful practice is better.  With dedicated surgical centers performing the most common surgeries repeatedly, you get better results.  That’s easy to see in the data about outcomes.  However, that doesn’t fit with the surgeon’s ego that says they get the best results.  They systemically discount their bad outcomes, ignoring them or explaining them away.  It’s what Thomas Gilovich explains in How We Know What Isn’t So.  When you know that more than 50% of surgeons believe they’re better than average, as professors and high school students did, someone has to be wrong.

What does this mean?  It means that physicians need practice and experience with a procedure to get good – and to remain good.  As a pilot, I must do so many take offs and landings in a given period of time before I can carry passengers.  Surgeons don’t have to do any specific number of appendectomies to be able to do one – but I’m not recommending they operate on themselves.  Specialization of surgeries to surgical centers allows for better outcomes.  Specialization among practice members for different kinds of surgery allows better outcomes for the entire practice.

Hope, At Any Cost

Nearly a decade ago now, I got to play a role in a drama at a pediatric hospital M&M (Morbidity & Mortality) session.  It was centered around “everything possible.”  It is a phrase that parents of children often use when speaking with the care team about what they should do to protect the lives of their children.  It’s also wrong.  The point was that there are some things that only extend pain and torment without adding any potential value to a child’s life – but are sometimes done anyway.  The point was to teach those in attendance that it wasn’t a literal plea but was rather a starting point for a discussion.  In pediatric and non-pediatric situations, people are often willing to give up more than they should for more time, because they can’t bear the loss.

Doctors are encouraged to provide hope when it’s not impossible and to offer ever life-extending options even when those options don’t increase the quality of the additional life but instead spread the misery longer.  They’re supposed to be the consummate professionals, being unwavering in their faith in new treatment options and their own skills.  However, the unfortunate truth is that, too often, we extend lives and try procedures that we would have been better off not doing.  “Everything possible” isn’t the right standard, but it’s the one that is often used.

The Care Guide

It was the late 1990s, and we did something revolutionary for a clinical study.  I played a small part in bringing best practice diabetes care to a primary care setting.  The program took in data and from it made recommendations about patient care based on the best practice standards at the time.  Spearheaded by a visionary endocrinologist and paid for by Roche (then Behringer-Mannheim), the program made a real difference.  The key difference, though, was the way that the recommendations were provided to the physician.  We gave them broad categories, and they either filled in the details or used the research and recommendations provided to them by the trained nurses – nurses they trusted.

The result was a success because we weren’t telling them exactly what to do, we were nudging them into the right direction and allowing them a bit of choice.  (See Nudge for more about this idea.)  We built trust with the providers.  We made the system work by playing into the culture instead of trying to work against it.  However, too often today, doctors feel like the systems are dictating care – and they’re no longer able to be doctors.


It’s a rather derogatory way of referring to the nurse practitioners and physicians’ assistants who offer up care in pharmacies and standalone urgent care clinics.  It refers to their need to follow the rules and do basic urgent care.  Come in with a cough, and leave with a prescription for antibiotics.  It’s the extreme form of what physicians fear.  The responses are largely scripted.  Nurse practitioners and physician’s assistants in most states work in a collaborative practice agreement with a physician who supervises the care they provide – and who is presumably their backup for problems that they can’t handle.

This has dramatically improved healthcare access in many ways – and it’s led to the over-prescription of antibiotics and, by extension, the emergence of multi-drug resistant bacteria.  People expect they can have treatment if they go to a doctor – even a doc-in-a-box.  As a result, many people leave with prescriptions that will do them no good.  Additionally, because they’re only taking prescriptions to feel better, they’ll often stop taking them before the infection is fully under control and will rebound with an infection that is mostly of variants of the infection that are least susceptible to the antibiotic – thus furthering the development of antibiotic-resistant bacteria.

Bias Toward Action

Built into our human psyche is a bias towards action.  There’s a bias towards doing “something” – even if that something ultimately turns out to be harmful.  Nassim Nicholas Taleb explains this in Antifragile, and it resurfaces everywhere.  We’re notoriously bad about waiting for things to play out.  As a result, we prescribe medications that do no good.  But more than that, surgeons can take an old saying to heart.  “A chance to cut is a chance to cure” is a common refrain from surgeons that exposes the belief that surgery is always an option to cure – even when it isn’t.  It may help the surgeon feel good that they’ve done “everything possible,” but that doesn’t mean it’s right.

Doctors Disconnected from the System

For most of us, we’ve got a positive view of our personal doctor.  We believe they’re competent above their peers, and we’re lucky to have them.  We also simultaneously believe that the healthcare system is broken.  We accept the gap between these two, even though our doctor is a part of the system.  The truth is that we treat our doctors like they’re separate and apart from the system they operate in, but that’s neither real nor reasonable.

Primary or Specialty?

It’s a simple pyramid.  There are lots of people at the bottom and few people at the top.  Fewer physicians/specialists and fewer patients.  If you want to make a big impact, where should you focus your energies?  Most people realize that the answer is the bottom of the pyramid.  It’s the day-to-day interactions with healthcare that are the opportunities to improve preventative care – but that’s not the way most healthcare systems prioritize investments.  Investments are made with specialists because they can charge premium rates and generate premium revenue.

Of course, working on the primary care isn’t fun or sexy.  It doesn’t necessarily feel like you’re making that much of a difference.  It’s small, incremental improvements, but those improvements are multiplied across many physicians and can make a huge impact.  The point isn’t the impact, the point is that it doesn’t “sell well,” either internally or externally.  There’s no marketing message to most efficient primary care – because patients don’t care about that.  There are messages to be sent about cutting edge procedures – that most people will never need.

Equal Treatment

In medicine, like justice, we expect that everyone gets the same treatment – that there are no biases.  However, the data says otherwise.  Just like we know that judges aren’t impartial, physicians aren’t either.  This is particularly true for physicians in ER settings, where triage is an expected part of the job.  In law, numerous sources (including Thinking, Fast and Slow, Complications, When, and Pre-Suasion) speak to the fact that judges are less likely to grant parole right before lunch, and, often, the more you appear like the judge, the more likely you are to be treated more leniently.  We like to believe that physicians are different, but the data says differently.


One of the central problems with the spiraling healthcare costs is the lack of a focus on prevention.  In a fee for service model, you get paid for doing more, and therefore there’s a negative incentive to work on preventative medicine.  This was a problem in the 1930s, when the Committee on the Costs of Medical Care (CCMC) met to discuss solutions.  They proposed capitation.  That is, they’d give physicians or medical systems a fixed fee per patient per year.  With large enough populations, the extreme cases are weighed out by people with little or no need in a year.  The incentives would then shift strongly to physicians doing preventative care, which is generally less expensive in the long run.  They’d make more money when they managed their patient population health well.

The problem is that nobody wanted it.  The physicians didn’t want their income tied to the behaviors of patients.  As we learned in Change or Die, as much as 80% of healthcare costs have behavioral roots, and changing behaviors isn’t something that physicians were trained for.  The resulting compromise was the Social Security Act – a far cry from what was intended but a win for citizens nonetheless.

When you create cultures and set up systems such that people are incentivized for the wrong things, you create bad outcomes.  It’s not that you’re getting the law of unintended consequences, as explained in Diffusion of Innovations, rather it’s that you’ve designed the system for bad outcomes.  Sometimes, those outcomes are a system that seems Uncaring.

Book Review-Understanding Beliefs

Why do we believe what we believe?  How do we know that the beliefs we hold are true – or that they’re held by others?  This fundamental philosophical problem of our existence is the one that’s addressed in Understanding Beliefs.  It’s a walk through the land of what beliefs are, how they’re connected to what we know, and how they can sometimes be distorted.

Procedural and Declarative Knowledge

We start by recognizing that there are two different kinds of knowledge.  The first kind, procedural, is know-how.  That is, how is it done?  It’s the kind of knowledge that Kate Pugh explains how to capture in her book, Sharing Hidden Know-How.  The second kind, declarative, is knowing that something is.  We know that the Earth orbits the Sun – at least we do now.

A large volume of our knowledge is in the form of our beliefs.  If we were to rewind the clock a few hundred years, we might be an outsider for expressing a view that the Earth orbits the Sun.  The Church might have us locked up for these beliefs as they did Galileo.  However, this represents a key problem.  Not only can we not articulate all our knowledge, as Michael Polanyi explained, but further we can hold conflicting beliefs.  (For more on Polanyi, see The New Edge in Knowledge and Incognito.)

While we expect that the beliefs of others should be thoroughly evaluated, our own beliefs remain largely unvalidated.  Much of what we “know” about the world will change given a few decades, but we have no systemic way of reevaluating our beliefs to ensure they match our current understanding of the world.  Consider the belief that atoms were the smallest unit possible against our emerging knowledge of electrons, quarks, and subatomic particles.  Our beliefs, due to the nature of our expanding understanding of the world, should change – but sometimes the process of changing beliefs gets stuck or slowed.

Runaway Beliefs

One of the other challenges with beliefs is that they’re formed by our experiences.  When engaged with others who hold similar beliefs, the degree of certainty in the beliefs can self-reinforce – and that can make even the false seem real.  Consider the Flat Earth Society, who believe that the Earth is flat.  Collected with others of the same mindset, they genuinely believe that the Earth is flat. even though it’s possible to demonstrate the curvature of the Earth easily.  From visual inspection mechanisms to the inability to explain satellites, it’s hard to believe the Earth is flat – but they do because it is continually reinforced to them.

Cults follow the same reinforcing dynamics.  Even those whose beliefs aren’t initially that strong are drawn to stronger beliefs through reinforcement.  This is just one explanation of why peer groups have such a strong influence on children – if their beliefs are close enough, and they’re spending much time together, they’ll coalesce and amplify.  (For more, see No Two Alike and The Nurture Assumption.)

Scientific Grounding

One of the hallmarks of good science is that it can be validated by others as true.  This, in turn, means that any hypothesis must also be falsifiable.  That is, there must be a test that could prove it false.  The hallmark of a scientist is that they’re willing to change their beliefs when the data doesn’t support their conclusions.  In a sense, scientists ground their beliefs in reality.  If they can’t prove something right or wrong, then the belief is suspect.

Principle of Parsimony and Occam’s Razor

All things being equal, the simplest explanation is generally better.  It’s called the principle of parsimony, or alternatively Occam’s Razor, and it’s been demonstratable.  Certainly, it’s not perfect, and some simple explanations are wrong; but time and time again, when people come up with complex explanations, it’s because they don’t really understand what’s going on.  In returning to Galileo’s case, there were numerous complicated calculations that were designed to explain the motion of the planets, because they believed in a geocentric model that placed Earth at the center of the Solar System.  We know now that this model was wrong, which is why they kept having to try to find ways to adjust for the errors that were invariable given an incorrect model.

This principle is often overlooked by conspiracy theorists.  They often posit that the entire world – or just the wealthy and powerful – are in on a scheme to convince us of a false truth.  Which is simpler: that the world is round, or that people for centuries have conspired to keep the truth of the Earth’s flatness from the general population?  I’ve seen too many cases of secrets getting out to believe that people can keep something that big a secret.  The Greenbrier Hotel’s secret bunker for Congress was kept secret for roughly 30 years.  (See The Cold War Experience for more.)  How can we believe that bigger and more complex secrets are being kept for more than ten times as long?

Black Swans

One important consideration about beliefs is that we often fail to recognize that logical reversals require reversing both parts.  The absence of evidence is not evidence of absence.  The Black Swan makes this point well.  Just because you don’t see it, doesn’t mean it doesn’t exist.  In the end, you may find that you’re better prepared to navigate conversations, conflicts, and life if you can start better Understanding Beliefs.

Book Review-Option B: Facing Adversity, Building Resilience, and Finding Joy

Option A isn’t available.  You can’t have what you want.  Whether you want a loved one back or you want something in your life that can no longer happen, you’ll have to do something different.  Option B: Facing Adversity, Building Resilience, and Finding Joy is what you do when you can’t have what you want.

The Backstory

The backstory for the book is that Sheryl Sandberg’s husband, David Goldberg, died.  She had to learn to deal with it.  Sheryl is (and was) the Chief Operating Officer of Facebook, and David was the CEO of Survey Monkey.  David had hired Adam Grant for a talk at Survey Monkey, and the couple had formed a friendship with Adam.  (For more of Adam Grant’s work, please see Originals, Give and Take, and Think Again.)

Though they’re listed as co-authors and despite the co-writing, the perspective is intentionally Sheryl’s.  This was done to create a consistency of story and to improve the flow of the book.  It must have been successful, because the book is a great path through the grieving of Sheryl and the children that she and David shared.

Meaning Reset

Five minutes into a meeting, you look up from your thoughts and wonder what everyone is talking about and, more importantly, “Why does it matter?”  Losing a loved one can have the effect of radically restructuring your perception of life and, as a consequence, what is important.  We all live by a set of expectations about how the future will be.  Couples expect to grow old together to watch their children’s children.  We don’t necessarily have a picture of the car we’ll drive or even the house we’ll live in.  We do, however, expect life to follow a somewhat orderly, forward progression.  If you lose a spouse or other loved one unexpectedly, the result is that your predictions of the future are invalidated in a moment – and that is disruptive.

Simple problems that needed no thought before consume you, because without the anchors you relied on, you feel compelled to consider every possibility and to look for ways that your perspectives may be wrong.  We’re suddenly launched into a world of doubt unlike any that you might have experienced before.

With our perceptions torn down and every decision requiring more thought, it’s no wonder that we’ll reprioritize things that previously would have fallen into the background.  Looking in, people are sometimes confused by the seemingly radical readjustment of priorities and meaning in someone’s life after a loss – but in the context of having to evaluate the guilt you have about the loss, it can make sense.


It’s hard to sidestep the “what if” game.  What if I had come home earlier, in enough time to help them?  What if I hadn’t told the girls I’d go to the movies with them?  What if the gun was locked up?  These games are instinctive after a loss.  Could I have visited more frequently?  Did I call them enough?  Did I tell them I loved them enough?

The problem is that there is no “enough.”  At the extreme, you could tell the other person you love them to the point where they couldn’t get a word in edgewise.  Certainly, that would be “enough” – or would it?  What if they didn’t hear it?  Wouldn’t they get annoyed that they couldn’t get a word in?  So how much telling them would be “enough?”  There is, of course, no answer to this question.

Guilt is practically unavoidable, and at the same time, it’s rarely deserved.

Waves of Sadness

The Grief Recovery Handbook is a good book on addressing our grief.  Though it – inappropriately – criticizes Kubler-Ross’ work On Death and Dying, it effectively makes the point that the emotions we feel after a loss aren’t linear, distinct, or prescribed.  We each experience grief in our own way.  However, what it doesn’t cover are the “deadly sneaker waves” of sadness.  In Iceland, there’s a magical beach where visitors turn their back on the ocean to their own peril.  What they call deadly sneaker waves wash onto the beach and pull people down and into the water.  Sadness can feel like this.

It comes seemingly out of nowhere, and it can knock us off our feet and tumble us in the surf.  We believe ourselves to be rational creatures in charge of our emotions.  We believe that we carefully regulate what we feel, and we’re rudely awakened when sadness washes over us.

Fortress of Solitude

Sometimes, the waves of sadness lead us to a fortress of solitude.  We push or block others out so that we don’t have to burden them with our sorrow.  Instead of allowing those around us to support us, we make a point to not be anywhere that they’ll be.  We create (or try to create) our fortress of solitude before we realize that we’re creating our own prison.

It might surprise you to know that many people will choose to self-administer a shock rather than to sit in solitude – for 15 minutes.  Being alone with one’s own thoughts is so painful that we’ll take a physical pain to distract us.  So, as we seek to be alone, we are inflicting pain upon ourselves.  Good friends will gently but firmly push us to continue to engage.  They won’t let us be alone.  Sheryl relates a small way that two of her friends went to a game for her son – after she said she didn’t need them to come.

Perceived Control

One of the chief issues with losing someone is that you recognize that whatever sense of control you had was just an illusion.  The belief that the world was orderly and safe came crashing in – and there was nothing you could do about it.  One of the ways that we cope with the slings and arrows of everyday life is our perception that we could – if we chose – change some of them.  We could deflect them or return fire in a way that would prevent them from happening in the future.  However, the death of someone close reminds us that nothing can be done.

Imagine, for a moment, there’s an annoying noise.  In one condition, there’s nothing you can do.  In the other you can press a button to make it stop – but it comes at a cost, one that you’re not willing to pay.  Which condition is more tragic?  The answer is the first.  The belief that we can stop something is more important than actually stopping it.


One of the odd things that happens when someone loses another is that their friends can end up distancing themselves.  As I explained in What If I Say the Wrong Thing?, there is no wrong thing to say – except nothing.  Sheryl explains that she considered carrying a stuffed elephant with her but decided against it, because she suspected that others wouldn’t get the hint.  There’s an elephant in the room when you’re not comfortable talking about it.  The truth is that some friends will move into the loss and hold you up when you can’t stand.  Others will step back and believe that they have no way of helping.  They don’t realize that often it’s their presence that is the help that those who are grieving crave.

The unfortunate reality is that people who lose someone close to them often simultaneously lose closeness with people with whom they had relationships but who couldn’t bring themselves to step into the space enough to be uncomfortable with the other person.  The best friends you’ll find can’t imagine being anyplace else except by a friend’s side who is hurting.

Principle of Non-Abandonment

Whether it makes sense or not to the outside world, one of the feelings that those closest to the loss will feel is that the person who has died has abandoned them.  It’s natural to feel a loneliness that they caused, and therefore they have, in some sense, abandoned you.  Parents whose spouse has died wonder how their spouse could have abandoned them to raise the kids.  That wasn’t the way it was supposed to be.  That wasn’t the deal.  The deal was together – but now the deal has been broken.

As friends and family move in and stay even in the midst of uncontrollable emotions, it helps to recognize that not everyone will abandon us.  The people who stay prove that abandonment by everyone isn’t inevitable – it’s not even possible.  The whole process of feeling abandoned doesn’t happen at an intellectual level.  It’s a sense of comfort to know that, even though you may be walking without your partner, you still won’t be completely walking alone.


Sheryl relates an approach from Susan Silk where you draw circles of proximity to the person who has died.  The closest people surrounded by the next closest and so on.  The key is that you offer comfort to the inner circles, and you seek comfort from those in the outer circles.  It’s a simple model for ensuring that the people who are closest receive the most support and receive it from the people who are close enough to be relevant.

It recognizes Megan Devine’s observation that some things can’t be fixed.  They can only be carried.  No one can fix the problem undo what has been done.  All we can do is carry the burden – ourselves – and as much of the burden as possible for those who were closer to the person who is gone.

Gratitude and Contributions

Even though some people find gratitude journaling helpful, not everyone does.  (For instance, I don’t.)  However, recognizing our power to help others is almost always helpful.  Twelve-step programs are big on service and helping others – encouraging everyone to get people to sponsor rather quickly.  They do this in part because there’s a straight line between self-esteem or self-image and the work that you do to support others.  Where gratitude is passive – and happens to you – contributions are active and are how you respond to the world.

Contributions don’t have to be large per se.  Small contributions are still contributions, and recognizing that anything that you can do to help others as you’re struggling can be amazing.  It’s when your capacity is least that the value of those contributions is greatest.

Change How

After an event of such proportions, you’ve entered a new world.  You’ve walked through a one-way portal.  The question isn’t whether you’ll change or not.  The question is how you’ll change and what you’ll change to.  You can choose to change in a way that shrinks your life, becomes trapped in victimhood, or you can choose to build your resilience, capacity, and contribution to others.

There’s no shame in whatever decision you might make.  Some battle with survivor guilt more than others – that is, the feeling that they should have died rather than the person who did and that somehow the world would be better off.  Guilt (believing that you did something wrong) and shame (believing that you are bad) inhibit recovery, and sometimes it takes a while to work through them.  (See I Thought it Was Just Me (But It Isn’t) for more on shame and guilt.)

Take It Back

Since our tragedy, Terri and I have met many others who have lost their child or children.  Some of them have chosen the path of shrinking their lives.  They’ve decided that since Christmas can’t be with their loved one, they just won’t have it any longer.  Whatever the special occasions are, they hide from them as if not celebrating them prevents them from happening without their loved ones.

For us, we have chosen the path that Sheryl describes as “we take it back” – their way of embracing those moments rather than hiding from them.  For us, we bought a new Christmas tree and new lights.  It was one of those things that we’d been talking about for years, but it was never important enough.  However, there was significance.  We could acknowledge and honor our memories of Christmas’ past and recognize that we’d be doing things a bit differently from here on out.

Our decisions didn’t stop there, but it’s the one that best represents the attitude.  We still struggle with our feelings as the waves of sadness crash over us, but at the same time, we can remember the good memories and recognize that different can still be good – well, at least okay.

Normalizing Struggle

Brene Brown calls it “gold-plating grit” in Rising Strong.  It’s the tendency to minimize the struggle aspects of life.  Sheryl and Adam recognize the need to normalize the struggle.  Kids of all ages need to understand that life is struggle.  Buddha taught all of us that.  However, struggle isn’t bad.  Struggle is necessary for growth.  (See The Psychology of Recognizing and Rewarding Children for more.)

What we need to recognize is that it’s not that we won’t have struggles but rather the results of the struggle will be worth it.  We can accept that we struggle if we know there’s a reason for it and the reason is a better life.  Sure, we wanted whatever Option A meant – that our loved one was still with us.  However, in the end, we may find that there’s a lot of good to be had in Option B.

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