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Book Review-Does Altruism Exist?: Culture, Genes, and the Welfare of Others

It’s an important question.  Does Altruism Exist?: Culture, Genes, and the Welfare of Others answers it.  Even the Dali Lama and Paul Ekman couldn’t come to a conclusion in Emotional Awareness.  Richard Dawkins argues that there is no “true” altruism in The Selfish Gene.  Robert Axelrod counters in The Evolution of Cooperation that cooperation at least may be adaptive.  Adam Grant in Give and Take explains that givers (those who would be considered cooperating or altruistic) are at the bottom of the pile – and the top.  Clearly, there’s more than meets the eye if there’s such confusion about the space.  It’s on Adam Grant’s recommendation that I picked up Does Altruism Exist? – so I could explore the space and the dynamics.

It’s All About the Motives

So, it’s not like people are denying reality.  They know that sometimes people do things that don’t benefit themselves directly.  The tricky part for those who deny altruism is the motivations.  They argue that altruism must be based on altruistic motives – and that can’t involve benefit to the person.  Even Richard Dawkins in The Selfish Gene shows where, in some cases, it’s possible that it’s statistically better to save others rather than yourself from a genetic perspective.  Consider a case where you could save four of your biological children but would lose your own life.  This is better for a gene, whose purpose is to reproduce.

The definition of altruism that David Sloan Wilson likes best is the one from William Scott Green: “Intentional action ultimately for the welfare of others that entails at least the possibility of either no benefit or a loss to the actor.”  There is, in this, no mention of motive.  Perhaps there’s a reason.  It’s impossible to know what lies in the hearts of others.  Often, we don’t even know ourselves what motivates us.  (See Thinking, Fast and Slow for more on this.)

The Characteristics of Altruism

If altruism exists, then what are the conditions that allow it to emerge?  After all, the tragedy of the commons is a frequently used example where bounded rationality of individuals can lead to tragic results for the group.  (See The Difference for more.)  How do we encourage the opposite?  The answer may come from Garrett Hardin in his article about the tragedy of the commons.  The proposed conditions are:

  • Strong group identity and understanding of purpose
  • Proportional equivalence between benefits and costs
  • Collective-choice arrangements
  • Monitoring
  • Graduated sanctions
  • Conflict resolution mechanisms
  • Minimal recognition of rights to organize
  • For groups that are part of larger social systems, there must be appropriate coordination among relevant groups

Given this set of constraints, it appears that prosocial, altruistic behaviors become more common for the good of the group.

Managing the Scale

It may be easier to scale up from Richard Dawkins’ genes to the scope of animals to see how altruism is baked into each of us.  If the individual competitors are the cells in our body, then we can begin to see how altruism doesn’t just occasionally happen – but builds on symbiosis.  The heart, lungs, liver, kidney, and other organs are all in a symbiotic relationship with one another.  None of them can exist without the others.  Each performs a special, differentiated function that the others require.  The network of dependencies ties all of them together inside the context of the animal’s body.

With this lens, we can see that cooperation and symbiotic relationships evolve with parts of the body.  Where it gets interesting is in the role of the immune system.  In the immune system, many of the cells are designed to directly encounter pathogens and engage them in “battle.”  In many of these skirmishes, the immune cell is destroyed.  It quite literally ceases life to combat infection from an invader.  This moves from symbiosis to altruism at a cellular level.

Selfishness Beats Altruism within Groups

All things work at multiple levels.  Inside a group, the selfish win.  Groups that are altruistic as a whole beat out more selfish groups.  It’s at this level that altruistic groups win – not inside the group itself but in competition with other groups.  While directly looking inside a group, it would be hard for us to see a reason for altruism to arise given the advantage of being selfish.  It’s only while looking at the inter-group dynamics that we begin to see that groups with higher degrees of altruism win – thereby preserving altruism.

Prohibitions Against Cheating

One of the key controls that more altruistic groups seem to develop is a prohibition against cheating.  In the ultimatum game, it’s the reason why people punish others.  When the balance gets too far out, it triggers our protections against being taken advantage of.  (See The Selfish Gene.)  This mechanism protects the altruistic from being crushed from within the group before the group can experience the intergroup benefit.

One could easily argue that the probability of developing prohibitions against cheating are very long.  It’s a specific interaction pattern that needs to be developed, and it’s not particularly likely that it will occur.  However, when we move the scale of time out to infinity, we can begin to see that not only can it happen but it will happen.  And because of the utility, one of the times that it does happen it will stick and be present from that point forward.  While we don’t know when humans – and some other animals – learned to punish cheaters, we know it allowed more altruistic groups to develop and for them to win against less altruistic groups.

Systemic Ethics

On the surface, it seems that we want ethics that are embedded into every individual – and certainly we want moral and ethical people.  (See Moral Disengagement for more on morals.)  Ethics, on their surface, seem to be cleanly defined.  However, as Kidder shows in How Good People Make Tough Choices, ethics are often tradeoffs.  Jonathan Haidt, which Wilson credits with his sharing of ethics being system based, explains in The Righteous Mind that the foundations of morality are common to everyone, but the way that we behave when they’re placed in conflict isn’t always the same.  Our societal values and perspectives shape the way that we respond when the foundations are in conflict.

It’s for this reason that we must accept that, while ethics are executed through individuals, their context is set at a collective or societal people.

Prohibited Behaviors, Not People

Forgiveness is an aspect of the broader set of skills that altruistic groups develop.  It’s not that people aren’t excluded for behaving poorly.  However, there must be a way for people to return to the group and the group’s good graces.  The thing that the group must prohibit is the behavior – not the person.  The regaining grace varies from situation to situation and culture to culture, but the concept of forgiveness plays an important role in the ability for individuals to learn the values of the group – and for the group to remain intact.

Belief in Ability

In a random system, the idea that the people that survived knew what they were doing – or know what they’re doing now – is fallacy.  The Halo Effect makes a key point that the world we live in is probabilistic – not deterministic.  That means that it’s not A+B=C but rather that random combinations of A and B often lead to C.  Because of this, it’s entirely possible that completely inept people rise to leadership or fame – and that people with great capabilities, capacity, and value are left in the struggle.  It’s natural to believe that people who are successful got there by talent.  The Organized Mind shares how we’re experiencing too much information and we’re taking ever increasing short cuts to cope.

One of the shortcuts is that if someone was successful before, then they’ll be successful again.  We ignore the work of Lewin that says that behavior (and, by extension, results) is a function of person and environment.  (See A Dynamic Theory of Personality.)  We know the conditions are different, but we expect that the person’s agency will drive the results we want regardless.

The Invisible Hand

Adam Smith believed in an “invisible hand” that guided the markets.  It can be that his invisible hand wasn’t some god-like force but was instead higher-level selection functioning in the market in ways that tended to offset lower-level abuses.  It can be that Adam Smith’s invisible hand is the answer to Does Altruism Exist?

Book Review-Perfectionism: Theory, Research, and Treatment

It would be nice to be perfect.  The idea that we’d never make a mistake, never be wrong, and never have to apologize has its appeal.  For most of us, it’s just an appeal.  For some of us, it is an expectation, and it’s one that leads us to a perpetual road of disappointment.  Perfectionism: Theory, Research, and Treatment is a book about people who feel the need to be perfect – even with the understanding that no one can be perfect.

Striving for Excellence

Before breaking down perfection into types, it’s necessary to address the rather obvious tension that exists.  On the one hand there, is achieving excellence – that is, the best possible outcome given the circumstances – and on the other hand, we must accept that we’ll fall short of perfectionism.  It’s not bad to strive for excellence.  Anders Ericsson explains in Peak that it takes a lot of work to reach the upper echelons of any endeavor.  Steven Kotler explains in The Rise of Superman how many of these peak performances can look superhuman.

When we’re talking about perfection and the need to consider that perspective, it’s not all bad – not by a long shot.  However, there are ways of pursuing perfection that are more – and those that are less – harmful.


It’s called maximization, and it’s a need to have the absolute best.  It doesn’t allow that you made the best possible decision for the time.  It’s being frustrated that the price of a television dropped weeks after you bought yours.  The problem with maximization is that we know people who maximize in more areas of their life are less happy.  (See The Paradox of Choice for more.)  The good news is that none of us maximize in every aspect of our lives – we couldn’t, because we’d exhaust ourselves.

Instead, we choose a strategy called “satisficing.”  This approach is a “good enough” approach.  We spend a few minutes looking for reviews and clues about what the right answer is, and we make the decision without fear that the decision we’re making isn’t the absolute best solution possible.  Instead, we’re weighing the tradeoffs in time and happiness of figuring out the perfect answer versus finding a good enough answer.

Perfectionists sometimes have other-focused perfectionism and that leads them to maximization strategies more frequently – approaching, but never reaching, all the time.

Self or Other

One key distinction in perfectionism is the dimension of self versus other.  This operates along two dimensions.  Where is the source of the perfectionism, and what is the object of the perfectionism?  When we have other-oriented perfectionism, we maximize more.  Other things and people need to be perfect for us to be okay.  When we’ve got internal-oriented perfectionism, we expect only perfection out of ourselves, and we can ruminate on our foibles and failures.

When we have other-oriented perfectionism, we tend to place unrealistic demands on others; as a result, our relationships often suffer.  We can’t help but to criticize, and, as John Gottman explains in The Science of Trust, that’s one of the four horsemen of the relational apocalypse.  Instead of accepting people for who they are, we keep wanting more.  (See How to Be an Adult in Relationships for more on acceptance.)  The Secret Lives of Adults shares how the way that we were bonded to our parents, and this may be one of the factors that lead to other-oriented perfectionism.

Self-oriented perfectionism can have complicated and potentially corrosive effects on our self-esteem.  When we expect only perfect, we can easily be let down as we find that our daily activities fall short of the standard.  This can, and often does, lead to depression and negative mental health effects.  However, it can also lead to greater resilience and a self-esteem that is based on positive accomplishments.  Which happens is driven in part by the gap between our performance and perfect expectations.  Just like the difference between PTSD and Post Traumatic Growth (PTG) are difficult to predict, the results of self-oriented perfectionism are difficult to predict.  (See Transformed by Trauma for more on PTG.)  Similarly, Nassim Taleb in Antifragile explains that it’s the degree and timing of challenges that differentiates between growth and collapse.

Sources of Perfectionism

The sources of perfectionism can be driven either externally or internally.  When we see perfectionism as internally driven, it is more pliable and therefore more likely to be molded and adapted to result in positive outcomes.  We can, for instance, relax our perfectionistic standards for our performance where necessary.

External, or social, perfectionism is more challenging.  We perceive that others expect perfectionism from us, and therefore it’s harder to adjust standards to allow for normal and natural faults and flaws.  In some cases, these expectations are real.  Others do really expect the person to be perfect – either because of their other-oriented perfectionism or because of societal expectations.  Alternatively, these may be misperceptions about others’ expectations.  We may perceive that we need to be perfect to be loved – but that’s not really the case.

Resolving other-sourced perfectionism can be more challenging.  There are three basic strategies:

  • Negotiate – In the case of someone else’s perfectionistic expectations upon you, you can seek to negotiate them, including what reasonable levels of performance should be and what collectively should be done if they can’t be met.
  • Refuse to Accept – If the perfectionism requirements are externally-driven, either through others or socially prescribed, you can refuse to take those on. This is easier said than done, because it may mean that a relationship or connection to culture must be lost; however, it’s still an option.
  • Exit – This is a more direct version of refusing to accept. It means that you sever the relationships and move into a place where those external demands for perfectionism no longer apply.

None of these options are easy – but they are possible when you’re encountering external perfectionism expectations.

Two Scales

While I’ve been introducing perfectionism, I’ve ignored the fact that there are two different, multifactor assessments of perfectionism – and that my description doesn’t directly match either of them.  The two instruments are Frost’s six-factor model and Hewitt and Flett’s three presentations model.

Six Factors

Frost’s model has six dimensions, four of which are self-focused and two are focused on parental demands as follows:

  • Self
    • High Personal Standards
    • Doubts about Actions
    • Concern over Mistakes
    • Organization
  • Parental Demands
    • High Parental Expectations
    • Parental Criticism

The parental demands perspectives can linger long after someone is an adult.  Those external voices often become internalized.

Three Presentations

Hewett & Flett’s model more closely resembles the way I’ve described perfectionism above.  The three presentations are:

  • Self Oriented
  • Other Oriented
  • Socially Prescribed

Here, I’ve simplified the source, because from a response space, the responses to other and socially prescribed are fundamentally the same – though obviously one operates at a larger scale.

Healthy and Unhealthy

In the right degree and with the right makeup, perfectionism can be healthy and adaptive.  It can help us become better humans.  However, it can also be neurotic, causing us mental anguish and suffering.  The real question about perfectionism is whether it’s productive, problematic, or pathological.  Obviously, we want to keep the productive aspects of perfectionism while preventing the problematic and pathological.

The real question is whether the desire for perfectionism is reasonable and realistic.  If you’re willing to adjust the expectations in the face of reality, it’s likely normal.  Conversely, if you’re feeling a compulsion to meet excessively high standards, it may be that you’re operating in the land of neurotic perfectionism.

The Role of Time

One of the keys to the difference between the neurotic and the normal may be the dimension of time.  It’s the difference between aiming for perfection and expecting it, seeking improvement rather than perfectionism right now.  Another factor that needs to be accounted for is that there are variations in all things.  Performance varies as does the felt need for perfection.  If we want to make perfectionism healthy, adding a bit of time may help.

Pride or Hubris

Pride is experienced as a result of a specific action or behavior, whereas hubris is associated with beliefs about oneself.  In Mindset, Carol Dweck explained how a growth mindset is focused on the effort put in and not one’s character.  It’s the difference between pride and hubris.  In Buddhism, there is a belief that being proud of others is positive emotion while pride for oneself is not.  (See Destructive Emotions.)  It may be that the goal is to avoid hubris.

Performance Based Love

One of the parenting factors that can influence perfectionism as adults is a tendency towards performance-based love.  That is, rather than a child believing that they’re inherently loved, they’re conditioned to believe that they are loved for the things that they do.  Love as a concept is important to humans as they develop, since we’re innately aware that we cannot survive alone.  (See The Blank Slate.)  If love is conditional, then our lack of perfection threatens our very survival.  That’s too much stress to have every day.  (See Why Zebras Don’t Get Ulcers.)

Perfect People Don’t Get Hurt

Extending beyond parental performance-based love comes the idea that perfect people don’t get hurt.  If you’ve been hurt before, and the person who hurt you made it seem like you’re fault, you may conclude that, if you want to avoid being hurt, you must be and remain perfect.  While this seems like a far-fetched idea, many people make victims feel like the oppressor’s bad behavior is the victim’s fault – particularly children.  Statements like, “I wouldn’t have hit you if you weren’t such a bad kid,” as distasteful as they may be, resonate and cause people to believe that it’s only through perfection that they can be safe.

High Performer Problems

For the most part, when we are thinking about those who would be suicidal, we expect them to match Thomas Joiner’s Interpersonal Theory of Suicide (see Why People Die By Suicide).  We expect them to be disconnected and feel like a burden.  However, another sad possibility emerges.  People who have perfectionistic tendencies tend to have cognitive rigidity and the same all-or-nothing thinking that leads too many people to consider suicide.

Instead of seeing the great things that they can do, they feel the weight – or burden – of the gap between their expectations and their performance.  That weight may even lead to thoughts of hopelessness.  Most people wouldn’t associate suicide with high performers – but because high performers have larger degrees of perfectionism, and perfectionism may lead to larger gaps between expectations and results, perhaps suicide is a risk for those who are perfectionistic.

Understanding Perfectionism may be the difference between happiness and death.

More Than Physical Trauma

It was 1988 when President Ronald Reagan proclaimed May as National Trauma Awareness month.  The proclamation was focused on traumatic injury.  Since the proclamation, we’ve learned more about the tragic effects of psychological trauma.  We’ve learned that psychological trauma is harder to see and sometimes harder to heal from.

Our work with trauma started when Terri would support children in the pediatric intensive care unit both as a nurse and as an advanced practice nurse.  Out of her experiences with physical trauma and the awareness of the need for parents and children to connect, we created our child safety cards.  At, you can find out more about these cards, which have child-drawn artwork and safety sayings based on CDC vital statistics about child injuries and guidelines from the American Academy of Pediatrics (AAP) recommendations.

In 2019, we published the book, Extinguish Burnout: A Practical Guide to Prevention and Recovery, as we recognized the powerful pain that people experience as a part of the hurts in their lives, including burnout.  Since then, we’ve been sharing solutions to vexing problems of mental health.  We’ve seen how medicine sometimes retraumatizes patients, and we are developing programs to help providers at all levels of the healthcare system to understand and respond to trauma in positive, helpful ways.

We also know that vicarious trauma is real.  Providers and first responders are themselves struggling to cope with what they’ve seen as they come face-to-face with the worst that humanity has to offer.  We’re developing programs to help here, too.  We want to provide the best support possible for those who are doing their most to lift humanity up in the darkest moments.

As with our other programs, we start with research – for this program, it means reading what is known about psychological trauma.  In honor of trauma month, we’re posting three weeks full of weekday book reviews.  We begin next week with supporting materials that provide context for understanding psychological trauma.  We speak of perfectionism, apologies, and altruism, so we can speak about their roles in trauma and trauma recovery.

Every day in the following two weeks – the start of May – we’ll be posting trauma-related book reviews along with book reviews that support a deeper understanding of trauma.  In total, we’ll have 15 book reviews supporting the first block of our trauma work.

We invite you to think about trauma not just from the physical impact point of view but also from the perspective of psychological trauma and how we can help people heal from it in the month of May.

Book Review-It’s How We Play the Game

Generally, I don’t read biographies.  For me, they’re boring.  However, Ed Stack became very interesting to me, so I decided that there must be more to him and his book, It’s How We Play the Game, than meets the eye – enough that it was a worthy investment – and I was right.

A Sporting Chance

Ed Stack grew up around his father’s sporting goods store – Dick’s Sporting Goods – and took it from a two-store organization in upstate New York to the retail powerhouse it is today.  The journey, as one might expect, wasn’t straightforward and wasn’t without peril.  Stack recounts the good and bad times in the book.  Certainly, from a business perspective, it’s a reminder of the hard work and luck that allow an organization to grow.  However, that’s not the interesting bit.  The interesting bit is how the experiences shaped the character of a man and, ultimately, an organization in a way that supports communities and helps children develop life skills they’ll need.

When I was growing up, sports weren’t a real option.  Two factors conspired against me.  First, there was always a shortage of money.  I remember breakfast cereal with powdered milk – because that’s what we had.  I remember our cups were recycled margarine cups.  Sure, others had it much worse than I did – but it meant that the idea of spending on sports wasn’t a priority.  A roof, food, and clothes were more important.

The second factor was much more powerful.  My parents couldn’t agree on anything and often consciously or unconsciously put my sister and I between them.  Stack acknowledges that his own parents’ divorce put the kids between them.  In my family, the conversations occasionally came up about doing sports, but the fact was that practices and games would be on the weekends sometimes, and weekends were hotly contested times between the parents.  It was clear pretty quickly that I’d never make it to stay on a team, because I’d never make the number of required practices and games.

To be fair to my parents, I’ve never been particularly interested in or good at sports.  It’s not something that interests me.  I’ve been honored to know professional athletes in many disciplines – baseball, football, and auto racing.  I respect what they have done – without getting so wrapped up in it that I’d believe I ever would have been very good.  (I know I should have a growth Mindset, and that Peak performance is just purposeful practice – but knowing one’s own limitations isn’t a bad thing.)

Foundational Beliefs

Woven throughout the story of Stack’s life is the dedication to the community and the recognition of the value that youth sports bring – even realizing that very few youth will ever make it to play professional anything.  That’s okay.  The foundation of hard work and teamwork is an important life skill – one that Stack credits with keeping him out of too much trouble.

For my part, I agree.  The focus of the Dick’s Sporting Goods Foundation on supporting youth sports programs is laudable.  It’s a good way to support the belief that sports build the kind of character traits that we all want to see in our youth, our adults, and our society.  Just because my son wasn’t good at soccer didn’t mean he didn’t play.  He played enough to learn some lessons and to hopefully develop some character that will serve him later.

The Shot

The truth is that I came to the book because I was curious.  We’re working on some firearms means restriction in the suicide prevention work we’re doing, and Dick’s Sporting Goods was expelled from the Firearms Industry Association (NSSF).  We were working with them to get safe gun storage information in the hands of as many people as possible.  Expelling one of the nation’s largest gun sellers seemed odd.

I learned that it started with the tragedies at Sandy Hook, CT and Parkland, FL.  Stack was touched by the tragedies, and both personally and organizationally took a stand to make a difference in protecting children from mass murder.  They removed all modern sporting rifles – assault rifles – from most of their stores.  They’ve also limited the number of handguns sold across their stores.

The tricky bit is that I can applaud Stack and the organization for being committed to take action to make things better.  I can even say that the moniker of modern sporting rifles is not the way I’d describe them.  At the same time, calling them assault rifles is probably not fair either.  Do I think that they should be as easy to get as they currently are?  I don’t know.  Certainly, Dick’s decision to remove them from the shelves made them slightly more difficult to get –but not in a fundamental way.  What it did was allow the executives at Dick’s to have a clear conscious – and I can respect that.

I’m not interested in entering into a Second Amendment debate.  Much like Stack, I have guns, I enjoy shooting them, and I want others to be taught how to use these tools.  I’d hate for people to say that I’m anti-gun, because I’m decidedly not that.  The nuanced challenge comes in whether the answer was the right answer – and whether NSSF expelling Dick’s makes sense.

As for Dick’s decision, the problem is that I know the numbers, and while the mass shootings are tragedies, they make up a trivial percentage of deaths by firearm.  It’s something that can compel someone to action, but it’s a drop in the bucket in terms of injury and death.  I don’t say that to minimize the suffering of anyone injured in the all-too-frequent mass shootings.  I say it to put things into perspective.  The leading cause of death due to firearm is suicide.  That’s not fundamentally changed in decades.  The non-mass-murder aspect of firearm deaths is a large portion of the remaining.  Accidental shootings and mass-murder are relatively trivial in comparison.

For NSSF, it makes sense.  Someone is publicly moving in a direction against where the firearm manufacturers and industry is going, they shouldn’t be a part of the industry association.  I’m not sure why they’d want to be.  I think the tragedy is that both organizations – NSSF and Dick’s – are aligned in the desire to prevent unnecessary deaths.  They’re both committed to finding ways to stop gun violence.  They just find themselves on opposite sides of a particular sub-group of the problem – and as I explained above, it’s a trivial percentage of the violence that’s happening.  For reference, modern sporting rifles or assault rifles are a trivial amount of the overall industry.  It’s a position and talking point, but it doesn’t move the needle in terms of overall sales of the industry.

Dreams of Greatness

The number of kids that grow up to be professional sports athletes is vanishingly small.  The odds of winning the lottery are also small – but people still play, because they can dream of winning.  There aren’t many people who will make the investments necessary to reach peak performance.  Though Anders Ericsson and Robert Pool’s research about what it takes to reach peak performance was oversimplified by Malcolm Gladwell, the truth is that becoming the best takes a lot of work – work that most kids won’t invest.  (See Peak for a summary of the research.)

However, what Dick’s sells when it comes to kids is the dream of greatness.  It’s not that anyone really believes that their child will break world records, it’s that they want to have the dream for a while, because it makes everyone feel better.

That’s at least part of the point.  It’s in learning how to play the game that we discover how to hope, dream, and live.  It’s How We Play the Game that matters.

Book Review-The Common Base of Social Work Practice

While today we might recognize the role of the social work profession, that wasn’t the case in the late 1960s and early 1970s.  That’s why The Common Base of Social Work Practice was so important.  It helped to explain what social work meant and what the gaps are towards becoming a profession.  It might be easy to dismiss such a work either because one isn’t particularly interested in social work or because social work is so well understood.  However, it’s an interesting exposé about how professions are formed and what the resulting challenges are.  While other professions have come to their own since social work, none that I’m aware of have a seminal work that so expertly exposes the transformation.

Throughout this review, I’ll be connecting what social work was going through fifty years ago with the kinds of challenges facing change management today – because I believe every profession goes through similar cycles.


In the primordial soup of a profession, there are numerous competing hypotheses.  There are different perspectives and views that must be reconciled to reduce the options to a manageable number.  It’s not necessary that every profession subscribe to a single model.  It is important, however, that the profession settle into a set of relatively compatible hypotheses that can work in concert with one another.

But that means there have to be competing hypotheses that can be tried and tested.  It also means there needs to be enough of them that their relative merits and weaknesses can be exposed.  Images of Organization explains that, even in understanding organizations, there are multiple models that make it easier to understand some aspects and more difficult to understand others.  Professions are no different.  These views, as they evolve, must be numerous enough to cover the space that the profession intends to cover.  Without enough models, there’s no room for testing.  In The Evolution of Cooperation, we learned how Robert Axelrod’s second run of the test for programs to win the prisoner’s dilemma resulted in sixty-two entries.  In change management, there are easily that many models – many of which are covered in the Change Model Library.

Richard Dawkins in The Selfish Gene coined the term “meme.”  It was conceived as an idea that self-replicates and becomes popular within an environment – not necessarily to the exclusion of other ideas.  Healthy hypotheses have a meme-like quality in that they replicate between minds – and ultimately mutate and join forces with other ideas to form something new.

The obvious question – which doesn’t have a clean answer – is when the refinement process is done enough to form a profession.  No one knows.  Eventually, someone makes a statement so profound that it resonates enough to gather people behind it.

Knowledge Building

On of the threads of my world has been knowledge management, which is and of itself is a bit of a misnomer.  Knowledge management is, in part, about knowledge building – the terminology used in The Common Base of Social Work Practice – meaning that there needs to be a consistent set of knowledge that everyone in the field has.  This has an inherent problem that one must first agree to what that common knowledge that everyone should have is – and that problem is harder than it might first appear.

There’s an irony about knowledge management in that it has no association to coordinate activities and develop it into a profession, and there is no common base of knowledge (or awareness) that every knowledge management professional must have.  It suffers from a lack of clarity about what should be inside and what should be outside the circle of knowledge management.

Basic Elements

A tension exists between the need to be able to communicate across disciplines and the need to have a language and approach specific to the profession.  There’s the need to define the basic elements that are inside the circle and those elements that touch the circle from the outside.  One of the observations was that social work was taking its cues from the psychology field – which, in turn, was built on the medical model.

Social work has largely settled on an approach that addresses the person in their environment, recognizing Lewin’s formula that behavior is a function of both person and environment.  (See A Dynamic Theory of Personality.)  While awareness of psychology is expected, social workers focus more on the way that the person interacts with their environment.

Theoretical Knowledge

It’s tricky.  In learning anything, you want to know how to use what you’re learning.  It’s important that there’s an application aspect that allows you to clearly understand how you’ll use the information.  (See The Adult Learner.)  However, we also know from The Art of Explanation that we need explain the overall landscape before delving into the details, so that learners have a way to connect what they’re learning.  That overall view requires a committing to some model for understanding the landscape – and ideally multiple models to avoid limitations in any one model.  (See Images of Organization for more.)

Ultimately, we’re concerned with the idea of “far transfer,” which is the application of learning well beyond the time and space that it was learned in.  (See Kirkpatrick’s Four Levels of Training Evaluation for more.)  Bloom’s Taxonomy of Educational Objectives might also look at this from an application or synthesis level when the components of learning can be combined with others in different situations to yield new and useful results.  (See Efficiency in Learning for more.)

Ultimately, the knowledge that social workers learn should be such that it can be applied to a variety of unpredictable situations.

Knowledge and Values

A profession is more than just knowledge.  While knowledge forms the foundation, professionals agree to a set of values that are consistent across the profession.  For instance, social workers explicitly agree in the need for dignity and respect of every individual.  They also believe that each culture has its own unique nuances and that cultural sensitivity is key.

Underlying every profession are a set of ethical standards.  It’s not just social norms.  It’s the challenges that Kidder describes in How Good People Make Tough Choices and the often competing foundations of morality that Jonathan Haidt describes in The Righteous Mind.

Occupation or Profession

The interesting question becomes when does an occupation or a career become a profession?  The defining characteristics of a profession seem to be a code of ethics, advanced or specialized education, and the perception of a higher level of skill or expertise.  I’d add to this definition that there must be a relevant problem that is being solved.  In Professional Learning x2, I explained that sometimes learning isn’t the point – sometimes the “paper” is.  When it comes to professions, we need solutions – not just the certification or license saying the person should be included in the profession.

The tricky part In the transition from occupation to profession – and the prestige that it conveys – is how to identify the skills and solutions that the profession will offer and what knowledge and training will be necessary to achieve that end.  Does every social worker need to be able to do individual-, group-, and community-level work?  Maybe – but maybe not.

Individual, Group, or Community

Social work broadly falls into three categories: individual, group, and community work.  Individual work is one-on-one with people who need help navigating and adapting to their environments.  Group work involves small groups of people who are being supported in growing their skills for adapting to their environment.  Community-level skills are trying to change the community as a whole.  Individual and group work is most similar to the work of psychologists, where community-level work requires a different set of skills.

Community-level skills effectively require an ability to see in systems.  Donella Meadow’s excellent work Thinking in Systems exposes the ways that stocks, flows, and loops create results in complex environments.  She explains how it’s possible to generate large impacts based on small inputs by knowing how the system functions and intervening in the right space.  Observationally, I’ll say I’ve seen a lot of social workers who are simply checking the boxes, doing the tasks, and have little or no understanding of systems or complex interactions.  (See Cynefin for more about different problem types.)  Too few have ever studied how to motivate people, how innovations are adopted, or the skills necessary to leverage a broader understanding to efficacy.  (See Diffusion of Innovations for more about adoption.)

In advanced practice nursing, there are two different kinds of roles: a nurse practitioner, who is an extender that allows medical doctors to see more patients; and a clinical nurse specialist, who helps change the relationship between the system, patient, and provider in ways that are more effective and efficient.  (I know I’m neglecting several other variants of advanced practice nursing in the service of simplicity.)  Both are advanced practice nurses, and both are trained with 80% or so of the same content, but their specialties are focused in different areas.  It’s possible that social workers need to have similar focus on whether they’re supporting individuals or systems.

Effective Helping

At the end of the day, the skill of a social worker is effective helping of people – whether they do it at an individual level or a community level.  It’s the effective assistance provided by a social worker that is the skill that justifies considering social work a true profession.  That builds on The Common Base of Social Work Practice.

Book Review-Loving Someone with Suicidal Thoughts

The thought of someone you love dying is terrifying.  The thought of them dying by suicide is even more so.  Too many people suffer and consider suicide.  Too many people who love them are tortured by their inability to stop the person they love from considering or attempting suicide.  The heart of Loving Someone with Suicidal Thoughts is learning to live in these terrible circumstances.

The Worry

Friends of ours, whose son died, admitted guilt about their feelings.  There were the unfathomable feelings of loss.  The feelings of disorientation existed, too.  They had the feelings that you expect with any death of someone you love.  It was doubled by the fact that parents aren’t “supposed” to outlive their children.  But what they were troubled by was the sense of relief.  They’d lived for years terrified that there would be a middle of the night phone call or a knock on the door at 3AM.  They were troubled by the sense of relief they felt, because their fears were finally over.  They would pick the worry every day over the actual loss, but they couldn’t help but admit that the relief was a part of what they were feeling.

I won’t pretend to fully understand.  I understand that sometimes the waiting is the hardest part.  While a rejection is infinitesimally small compared to the loss of a child, sometimes the rejection is better than the waiting for someone to decide.  The fear of what may happen is worse than what does happen.  When it comes to suicide, this isn’t true.  The hardest part is the finality of the loss of someone you love.

I do not share this to encourage people to die by suicide.  I share it so that we can recognize that those who love someone with suicidal thoughts are in their own torture.  Healing for the suicidal loved one is healing for everyone.

Am I Not Enough?

Widows of husbands who have died by suicide are prone to ask, “Wasn’t I enough?”  In the frame of the present, loving someone with suicidal thoughts leads to natural self-doubt.  If I were better, then they wouldn’t have suicidal thoughts.  Love is supposed to conquer all, just like in the movies – so if it doesn’t, then I must be doing something wrong.  Brené Brown explains in I Thought It Was Just Me (But It Isn’t) how we all question our value and how we need to accept our inherent value and know that we are enough.

That leads to a painful realization that there may be times when we don’t have enough control or influence to prevent the results that we don’t want.  We love the illusion of control.  (See Compelled to Control.)  However, the truth is that we have much less control than we would like to believe.

The Impostor

“Nobody would like me if they really knew me.”  Impostor syndrome is the sense that you don’t really belong where you are.  You don’t think you know enough.  You don’t think you’re good enough.  You wonder how you’ve managed to fool everyone for so long and, more importantly, when they’ll figure out that you’ve been pulling the wool over their eyes.  (See The Years that Matter Most for more.)

The fundamental premise is that there’s a gap between the way that someone is appearing and the way they really are.  It starts small.  We hide a part of ourselves, because we don’t expect that others will appreciate it.  (See No Bad Parts for more about different parts of our psyche.)  Over time, we’re reinforced that people like the person we’re showing them, and we begin to progressively believe that they only like the image we’re projecting – not the real person.  This leads, ultimately, to people believing that the parts they’ve hidden must stay hidden, and that people wouldn’t love them if they knew the real them.

In most cases, the people who love you already know what it is that you want to hide and are just allowing you to hold it back in respect for your choices.  We hear this all the time as parents have a child come out as homosexual.  Friends sometimes comment that they’ve known for years but respected them enough to wait until they were ready to discuss it.

While this isn’t a universal reaction, it happens often enough that it calls into question the idea that people don’t really know you.  Sometimes, they can know more about you than you do – and they love you still.

Always a Choice

Once suicidal thoughts have come to someone, particularly if they’ve ever made a plan, it’s always on the menu.  When they stub their toe, waiting on it to stop hurting, taking medication, or dying are the options.  It’s not that suicide isn’t a very bad option – it’s that because it’s been recognized, it remains a recognized option.  It takes some conscious effort to remind oneself how bad an option it is – and that it might be good to take that option off the table for now.

One of the problems with suicide screeners is that they can’t distinguish between people who have had a plan and know better than to use it and those who have newly formulated a plan.  It’s hard to discern the difference between someone who has their world well under control and those who are barely hanging on.

Universal Warning Signals

There’s a persistent myth that everyone who dies by suicide has sent detectable warning signs.  (I prefer signals to signs because signs sound clearer than the average suicidal person is.)  The problem with the desire to find this is laid out in Rethinking Suicide and in Myths About Suicide.  Some people, possibly more than 50%, don’t consider suicide more than a few hours before their death.  If they don’t know themselves, what kind of signals are they sending?

Not only must the suicidal person send a signal about their intent it must be detectable.  Most of the warning signs list include a dozen or more things, and those things have a very low predictability for whether the person is or is not suicidal.  In fact, the American Association of Suicidology (AAS) once proposed an acronym, “IS PATH WARM?” as a set of warning signs for suicide – that is, until the research showed that it wasn’t effective.

For me, I focus on clear, loud signals like the following: directly indicating they’re planning to die by suicide, giving away all their possessions, or explaining that it doesn’t matter because they won’t be around.  Those are clear, detectable signals; things like changes in mood or behavior aren’t, because many people change their moods and behaviors without considering or attempting suicide.

Feelings, Beliefs, and Facts

How we feel, our emotions, are undeniably our experience.  We feel the way we feel – and no one outside of us can say we do or don’t feel a certain way.  However, that doesn’t mean that the feeling is congruent with reality.  We can feel unloved and be loved deeply.  We can feel lonely in a crowd.  We can be alone and not feel lonely at all.  (See Loneliness for more.)  Because we feel it, we think it’s truth when it may not be, as Lisa Feldman Barrett illustrates in How Emotions are Made.

Similarly, we trust our beliefs as facts when we shouldn’t.  In fact, research shows that we routinely fail to search for ways to disprove our hypotheses.  In the famous Wason selection task, less than 10% of participants could correctly identify how to properly ensure that the provided conditions and rules matched.  There’s plenty of other research to indicate that we’ll sometimes cling onto beliefs that we should know are wrong, but we’ve invested too much in them.  Going to Extremes walks how this can be used to create radical groups.

The natural bias to accept our feelings and beliefs as facts sometimes leads us to believe we’re unworthy or unloved when the truth is radically different – and we can cling to this even if we’re faced with irrefutable evidence that this isn’t true.


One of the most important tenets of Buddhist philosophy is the idea of detachment.  The idea is that the more attached you are to your views and the outcomes, the more suffering you’ll feel.  (Suffering is another major tenet.)  (See Resolving Conflicts at Work for more on detachment.)

When loving someone who has suicidal thoughts, detachment may be more than you can muster – and you wouldn’t be alone.  The one step that you may be able to take is to listen without judgement or resistance.  Maybe you can listen without becoming attached to the words in a way that you feel you’re responsible or have any control of the outcomes.


Many people don’t understand that courage isn’t the absence of fear, it’s the presence of fear and proceeding anyway.  (See Find Your Courage for more.)  I can’t think of anything more courageous than loving someone with suicidal thoughts.  You are constantly afraid that they’ll decide to take their own life, and the best you can do is love and support them through it.  It’s an impossible situation in which too many are placed.

It’s courageous to say to your loved one that you want them to feel better, so they’ll stay, instead of trying to coerce or manipulate them into compliance.  (See Motivational Interviewing for more on non-coercive, effective strategies.)


There’s a temptation – even among therapists – to treat every mention of the word “suicide” as an emergency requiring a call to 911.  However, we know that many 911 calls end in tragedy – particularly with people who have mental illness or are suicidal.  (See People in Crisis for more about suicide by cop.)  While being present with someone who has suicidal thoughts is scary, it doesn’t mean that 911 is the right answer.  Calling 911 may be the right answer if they’re in imminent physical harm or they’ve made an attempt that you’re aborting.  If they’re pre-attempt and you need help, the national mental health hotline at 988 is an option to get tips and support for your loved one.

As the moments move to days, there’s another pull to have someone committed to inpatient treatment.  In the cases where it can be done, it may still not be the best answer.  It necessarily deprives the person of their freedom and sense of autonomy.  It often substantially damages relationships to the point they cannot be repaired.  To make the decision to have someone involuntarily committed to an inpatient program is very risky for the relationship and not particularly protective of the person, as the probability of suicide after exiting an inpatient program is roughly 300x.

Sometimes, the best you can do in the moment and in life is to keep Loving Someone with Suicidal Thoughts.

Book Review-People in Crisis: Understanding and Helping

A crisis is a temporary inability to cope by means of our normal problem-solving devices.  People in Crisis: Understanding and Helping is designed to teach the means by which we can help people through their crises and to reach the other side by helping them better process their circumstances.

Danger and Opportunity

Crises are inflection points.  They’re points where there is great danger and threat of an inability to process or recover – and, simultaneously, they’re the threshold of opportunity.  The Chinese symbol for crisis is formed by the symbols for danger and opportunity.  The first step in a crisis is to help people see past the danger of the situation and to recognize the opportunity that is a part of the crisis.

Identity Issues

One of the key kinds of crises that people face are crises of identity.  Erik Erikson in Childhood and Society outlines a set of stages that he believes children go through.  Each of these stages causes us to alter our internal view of our identity, and therefore these transitions are periods of identity crisis of varying intensity.

We also face identity issues when we are not able to reconcile the way that we’re behaving with our ideal versions of our identity that we hold.  In How We Know What Isn’t So, Thomas Gilovich explains how we’re able to delude ourselves about our grandeur.  Sometimes, the gap in our self-perception is pointed out to us in ways that cannot be ignored.  Kim Scott, in Radical Candor, advises us to be direct in ways that can make it impossible for us to ignore the discrepancy between our identities and the results we’re seeing.  This all leads to a crisis of identity that may be small or may be large.

Blame the Victim

One of the negative aspects of our culture today is the tendency for us to blame the victim for their misfortune.  You may have heard “ye of little faith” as a subtle attack on the piety of others.  It was believed that misfortune befell those who were in God’s disfavor.  Today, we have a view that bad things happen to good people, and misfortune happens to all of us.  Despite this, we still will tend to wonder what someone has done to deserve their fate.

Albert Bandura calls this “victim locus” in Moral Disengagement, and he doesn’t believe it’s a good thing.  It unfairly judges people when they’ve done nothing wrong.  The Halo Effect explains that we live in a probabilistic, not a deterministic, world.  That means bad things can happen to good people.  Sometimes, there isn’t someone to blame – even if that make us feel more comfortable.  We want the perception that we have control of the outcomes that befall us – even if that control is an illusion.

Perception Matters

Compelled to Control makes it clear that control is an illusion.  Despite this, it’s an illusion that we like and want to keep.  Numerous studies have shown that we have less distress with unpleasant situations when we believe that we can stop them at any time.  Whether we can stop or have influence on the situation makes little difference.  What makes the difference is that we believe we have control.  (See The Hope Circuit for more.)

The reach of perception extends beyond simply the perception of control.  If we are willing to perceive that our circumstances are neutral or good, then we’ll feel happier.  We’re not talking about delusional thinking.  We’re talking about intentionally shifting your perception towards a place of acceptance of the circumstances and reveling in the positives, as Rick Hanson explains in Hardwiring Happiness.

Navigating the Crisis Maze

We build mental maps and models of our world.  Gary Klein in Sources of Power explains how firefighting captains have learned how fires work.  They have a model for fires, and it’s disconcerting when their models predict that things will happen, but they don’t.  Sir Conan Doyle’s Sherlock Holmes character would call it “the dogs that don’t bark.”  It’s a small thing but a noticeable one.  The fire captains generally pull people back and build a new working model for the fire – hopefully, a better one.

Crises generally involve one or more fundamental beliefs that have been called into question or destroyed.  A parent that loses a child must release the “natural order” argument that they’ll die before their children.  It’s a fundamental – if unstated – part of the rules of living and a significant portion of the mental map.  More impactful is the couple who have lived together for decades and one person dies – or chooses divorce.  The map of the world had adapted to having the other person in it – and now it has to adjust to their absence.

It’s no wonder why being in crisis is so disorienting.  Our way of navigating the world is broken or bent, and we’re not sure what parts of our mental map we can and cannot use.  Navigating a world that has become a new and uncharted maze is very scary, and it’s why people coming alongside us during a crisis makes it better – particularly if they seem to know how to navigate the maze.

Replacement Families

In an ideal world, we’d have ideal families and would have developed secure attachment patterns.  (See Daring to Trust.)  We’d have families who loved us unconditionally and never judged us.  They’d be ever-present when we needed them.  However, we don’t live in an ideal world.  In fact, there are few constants more real than the fact that all families have their own dysfunctions.  Every family has aspects that don’t work well – but we’ve adapted, because that’s the way they are.

Increasingly, we’re finding ways of augmenting our social connection needs with friends.  Our friends become our replacement families.  When we need the support that a family might have at one time provided, we lean on friends instead.  Certainly, things are changing in our social capital relationships.  Robert Putnam explained this decades ago in Bowling Alone and more recently in Our Kids.  Sherry Turkle explains in Alone Together how our dependence on technology has made us more connected – yet less personally connected.

The good news of all of this is that it’s easier for people to find support in other ways when their families aren’t able to support them the way they need to be supported.

Sick Role

It’s sometimes too easy to find others to help us.  It starts to make the role of being sick too desirable and too easy to get into.  When someone identifies themselves as ill – or they’re identified as ill by others – they’re automatically granted certain graces that wouldn’t normally be available.  No one expects people who are ill to split wood and bring it inside to man the fire.  Instead, we grant them a pass and pick up the load.

There’s a delicate balance in play here that often gets out of whack.  We should allow people time to heal, and we should support them – as we would want to be supported.  However, at some point, we need to get people out of the sick role so they can work on healing and returning to fully functional members of the society.  One of the keys to getting someone out of a sustained crisis is to help them release their victim role.  We need to help them find a way to tentatively return to the fully productive world of accountability.

The Power of Caring and Sharing

When you’re looking at how you can help people in crisis, the answers may be unsatisfyingly simple.  It can be that the best way to help someone is simply to let them know that you care and to listen to them share.  If you look at the research about the efficacy of psychotherapy, there’s one clear factor that matters more than anything else.  It matters more than the type of technique you use or where you got your training.  The Heart and Soul of Change explains that it’s the therapeutic alliance: how much you connect with and believe that your therapist really cares.

You don’t have to be a therapist to connect with other humans, and that can be a powerful way of radiating healing.  In Why and How 12-Step Groups Work, I explained that much of the power of the groups is the new communities that form around people.

The appropriate strategies for sharing can be equally helpful.  Whether you use Motivational Interviewing or something else as a strategy to engage people in the process of telling their story, there’s something to it.

Suicide by Cop

Sometimes, direct strategies don’t work.  The genetic drive for self-preservation can be a difficult thing to get past even for those determined to die.  Sometimes, self-preservation diverts things into behaviors that are harmful in the long term – but aren’t immediately life threatening.  People have taken up alcohol, overeating, and drugs in an attempt to soothe their pain but also to create a scenario where their death is more likely.  Sometimes the strategies for indirect self-harm involve other people.

I remember the first time I heard it.  My brother-in-law at the time was a cop, and we had just watched a news story about an officer-involved shooting in his basement.  I didn’t really think that it was all that interesting when he told me that it was an officer-assisted suicide – and later “suicide by cop.”  When I asked more about it, he shared that people will provoke officers to the point where they have little or no choice but to shoot – and kill – them.  Afterwards, they’d learn that the gun wasn’t loaded or wasn’t real, but the person who ultimately would die would intentionally create the perception of a real threat.

People in crisis – who want to die but aren’t able to do the degree of self-harm necessary – often do strange things.  Sometimes, it’s simply risky behaviors; other times, it’s intentionally provoking their death.

Intimate Partner Violence

The degree to which women are harmed by domestic partners – or intimate partners – is staggering.  The research seems to suggest that the problem has been going on since the earliest days of humanity and that it’s finally being discussed more.  That doesn’t make it better.  One of the key questions that gets asked is, “Why doesn’t she just leave?”  The answer to that is complicated.

In Divorce, we learned that most women’s economic status decreased after a divorce.  In short, they’re less capable of meeting their basic needs than they were when they were married.  It’s also true that, before divorce laws were changed in the US, it was harder to get a divorce without a clear reason.  Of course, not all intimate partners are married, but there’s a clear answer that the economics of the situation may play a role.

The more tragic version of this story is that, despite protective orders and social protections, women who leave are often those who are harmed.  Their departure creates an anger in their partner that erupts into violence.  That violence can visit upon them as a murder-suicide or simply battery, and it can happen no matter where they reside.


One of the things that hold people in crisis is a sense of shame.  Coming across a situation that you don’t know how to process is natural, but when you start to focus on judging yourself for the situation, it becomes harder to resolve.  Certainly, there are situations of our own making.  We make bad decisions, and we end up with consequences that we don’t like.  We can feel guilty for those bad decisions, but when it changes from we made a bad decision to we are a bad person, there’s a problem.  (See I Thought It Was Just Me (But It Isn’t) for more on the difference between guilt and shame.)

Bad things happen to good people.  It’s simple truth, but it’s sometimes hard to accept when you believe that you had a hand in the circumstances that you’re in.  This is particularly hard if you’ve been struggling with the same sets of behaviors and feel as if you’re continuing to do the things that you rationally don’t want to do.

Few people have heard about Jonathan Haidt’s Elephant-Rider-Path model, which explains that our rational beliefs are a tiny rider on top of a huge, emotional elephant.  (See The Happiness Hypothesis and Switch for more.)  The rider believes he’s in control, but the elephant always wins when he wants to.  We make rational decisions to lose weight or stop drinking, but our emotional elephant has different plans.  Our rational rider holds the reins with all the willpower they have but eventually loses their grip.  (See Willpower for more about willpower.)  Sometimes, losing the grip means that we feel ashamed that we can’t keep from the thing we don’t want.

We forget that willpower is exhaustible, and if we don’t change the systems around us and deal with the emotional hurt that drives us to the bad behaviors, we’re unlikely to permanently resolve the bad behavior.  That’s nothing to be ashamed of.  It’s something to recognize, but it’s often shame-inducing for some.

Opening Pandora’s Box

Helpers’ discomfort with certain topics can prevent people from getting help.  Abuse, suicide, death, and other difficult topics aren’t the kind of things that anyone wants to discuss – but sometimes we need to discuss them, especially if we want to be helpful.  Helpers often fear that, by asking difficult questions, they’ll “open Pandora’s box,” causing harms to spill into the conversation, the relationship, and the world.  While opening up the discussion on these sorts of difficult topics can require a bit of time to address well, it’s not like these things are contagious.

The way to talk about any difficult topic is to address it directly.  The advice, from The End of Hope and others, is to open up about secrets.  Not talking about a topic doesn’t make it go away – it only makes it fester in hiding.

Learning, Earning, and Returning

One of the perspectives of human lifecycle is that it’s three phases.  There’s a phase of learning – perhaps through the time of college.  There’s a phase of earning, where you’re earning a living, making money, and generally striving.  The final phase – retirement – is a phase of returning.  It’s a time of your life when you make an attempt to give back to and support others.  Retirement is often seen in the US as an opportunity to kick back and relax.  It’s a time to stand by and watch the rat race.

These three phases are punctuated by crises between them.  Deciding how to make money, to take the leap into a corporate rather than educational environment is challenging.  So, too, is the transition into retirement and the awareness that you’re no longer earning money, or at least not much money.

The way to find meaning in this last transition is to discover your why.  Simon Sinek in Start with Why and Clayton Christensen in How Will You Measure Your Life? explain the importance of having a purpose for your life.

Death of a Child

The worst thing in my life to date is the death of our son.  However, it’s more than the acute loss that I feel because Alex is no longer here.  There’s another aspect.  It violates the way that the world should work – or that I understand the world should work.  No parent should have to bury their child.  When you lose a child, you not only face the loss, but you must also contend with the fact that the world doesn’t work the way that you believe it should work.

It doesn’t require the death of a child to be in crisis.  However, sometimes that’s the reason why you find People in Crisis.

Book Review-Alternatives to Suicide: Beyond Risk and Toward a Life Worth Living

It’s a worthy question.  What are the alternatives to suicide?  That’s the question that Alternatives to Suicide: Beyond Risk and Toward a Life Worth Living attempts to answer with its subtitle.  How do we transform the pain that people feel and their desire to die?  Though an academic volume with multiple authors and the readability challenges associated with both of these aspects, the answers that you find may surprise you.

Flip a Coin

One of the depressing and discouraging statements about the predictability of suicide is that even the best work on screening, assessing, and predicting who will die by suicide in the short term is only slightly better than the odds of flipping a coin and getting heads.  Estimates vary about the ability of assessment to predict suicide, but they’re in the 50% range.  While the behaviors we’re doing imply that we’re much better at determining who will and won’t die, the realities are different.

Interact with healthcare, and you’re likely to be confronted with a set of questions about your suicidality.  It may start with depression and hopelessness, or it may directly ask about suicide thoughts, but you’re likely going to be asked.  Frequently, we see PHQ-2 (Patient Health Questionnaire-2) asked – and if the person answers in a way that’s concerning, they are automatically asked the PHQ-9 (Patient Health Questionnaire-9) questions.  Sometimes, people use the Columbia Suicide Risk Screener (CSRS) or the Ask Suicidal Questions (ASQ) screens.  The stories of patients being encouraged not to answer in a way that would trigger concern are perpetual.  No healthcare provider wants to do the extra work, nor do they want to see the person held for extended periods of time waiting for one of the few people trained to do a formal assessment.

It’s called universal screening, and it’s a requirement by accreditation bodies.  They require that you have the process if you want to receive their stamp of approval.  And because their accreditation means that you can bill insurance and the Centers for Medicare and Medicaid Services (CMS) – which is almost all of a hospital’s business – hospitals do what the accrediting body requires whether there’s efficacy or not.

That Which Needs to Stop

Shneidman described suicide as a way to stop psychic pain that he called “psychache.”  (See The Suicidal Mind.)  One of the common factors in suicide is a desire to stop something – whether it’s directly called out as psychological pain or not.  With the cognitive constriction that accompanies a suicidal crisis, people may not be able to see other solutions to stopping their pain – except suicide.  (See Cognitive Therapy for Suicidal Patients for cognitive constriction.)  The key to finding alternatives to suicide is to find alternative ways to stop the pain without stopping their heartbeat.

Dysregulation Vulnerability

The research is inconclusive.  Some believe that all suicidal people exhibit signs and create invitations for others to intercede for them.  Others look at research on suicide attempters that leads to the conclusion that many attempts – greater than 50% – were not considered a few hours before the attempt.  Because of these numbers, studies have attempted to connect suicide with impulsivity – with very little success.  The measures we use for impulsivity seem to not effectively capture the possibility that someone will consider suicide.

However, when the focus is changed to skills for emotional regulation, the story changes.  It appears that those who are more capable of emotional regulation are also more capable of riding out the short term storms that seem to lead too many to suicide.  It’s like Mischel’s Marshmallow Test has an impact on preventing suicide as well.  Learning that things will likely get better if we can just wait a bit seems to protective.  Rick Snyder in The Psychology of Hope explains that hope is made of willpower and waypower.  Waypower is understanding the path forward.  Willpower is that capacity to hang with it and keep trying.  (See Willpower and Grit for more on the power and makeup of willpower.)

Meaning in Life

Viktor Frankl famously wrote that “Those who have a ‘why’ to live, can bear with almost any ‘how’.”   (See Man’s Search for Meaning for more.)  Meaning in life – even a little meaning – can be a powerful protective force.  Simon Sinek believes that everyone should Start with Why.  It’s about finding meaning in your life, and that meaning can be small.  As Atul Gawande explains in Being Mortal, giving patients even something as simple as a plant to take care of can help them live longer lives.

We crave the idea of being useful.  Thomas Joiner’s Interpersonal Theory of Suicide (IPS) posits that lack of connectedness, feelings of burdensomeness, and ability to inflict self-harm all drive suicidal behavior.  (See Why People Die by Suicide.)  Being helpful to something or someone else directly combats that feeling of burdensomeness.


Robert Putnam signaled a problem when he wrote Bowling Alone.  Social capital – our connections with others – were eroding, and no one knew what to do about it.  Sherry Turkle takes it further in Alone Together, as she describes how we are becoming technologically connected and interpersonally disconnected.  There’s been an assault on our feelings of connectedness – and it’s not getting better.  In 1990, about 75% of us felt we had a best friend.  By 2021, that number is down to about 59%.  In short, if connectedness to others is a protective factor against suicide, its impact is fading.

Three Step Theory

Klonsky and May built on Joiner’s IPS theory and proposed that it’s a three-step process to get to suicide.  The three-step theory posits that pain and hopelessness move people to the first stage of suicidal ideation.  To get to the second step, they propose that pain must outweigh connectedness.  The final step of attempting suicide requires the capability to attempt – or the capacity for self-harm.  Generally, this is the integration of an ideation-to-action framework with Joiner’s IPS theory such that the process of getting from idea to action has a path.

The caution that I’d have with the three-step theory is that the process of the three steps can potentially happen very, very quickly.  It’s still a framework, since pain and connectedness aren’t quantified into scales that can be measured against one another in an objective way.  It’s about the person’s perception – and that is often colored by cognitive constriction.

Who Failed Who

Bumper stickers of people who have rescued dogs ask the question, “Who rescued who?” implying that the dog may have saved the person’s life.  While, in the case of the bumper sticker, it’s not meant in the literal sense, there’s often a reversal that happens when a treatment fails to move from blaming the practitioner or the process and instead transferring the blame to the patient.

We know that this isn’t right, that it’s frequently not the patient who failed but rather the poor therapeutic alliance, the skills of the professional, or the technique itself.  However, that doesn’t prevent many people from defecting the blame and placing it on the patient.  (See Mistakes Were Made (But Not By Me) for more.)

Once There’s a Plan, There’s Always a Plan

One of the challenges with suicidal ideation is that even the mental health professionals, whom you would typically seek out for help, are often disturbed by the word suicide and reflexively move to defend themselves.  Litigation around suicide encourages providers to suggest emergency rooms and hospitalizations at rates substantially more frequent than would otherwise be prudent.  Instead of focusing on the patient and what they need, the provider moves to protect themselves – whether it’s good for the patient or not.

One of the bigger problems with suicide assessments is that once you’re high risk, you never move back down the risk scale.  Whether you’ve made a previous suicide attempt or you’ve just developed a plan for your suicide, there’s no backing down from the high-risk category.  You see, if you’ve tried once, you may have figured out what you did wrong in your plan.  If you’ve “only” planned a suicide, they know you’ve got an idea how you’ll do it.

This neglects the basic understanding that once you’ve created a plan, it will always stay with you.  It’s not the sort of thing that you forget.  You can’t.  (See White Bears and Other Unwanted Thoughts for more.)  Therefore once you’ve developed a plan once, you’ll always be at an elevated risk – no matter what your risk for suicide is in the moment.

Tactics like suicide contracts for those professionals willing to treat people who dare say the word “suicide” are more for their benefit than the patients.  It absolves them of some responsibility if they believe that the patient committed to telling them despite ample evidence that safety contracts make patients none the safer.

Ultimately, this is the result of professionals who believe that they’re responsible for preventing patients from dying by suicide.  The truth is that if someone really wants to die by suicide, you’re not going to stop them.  (See Suicide: Inside and Out.)  Instead, it’s healthier for the person who is suicidal to accept that it’s their responsibility to keep themselves alive and the professional is just someone on the team to help make that happen.  It’s powerful for the professional to admit to themselves and their patients that they’re unable to save anyone at all – they always have to save themselves with help.

Suicide is the Solution, Not the Problem

Okay, it’s a bad solution.  However, suicide is a solution to problems and pain.  Only the patient themselves truly knows the entirety of their life, their experiences, and their pain.  We can, from the outside, only get glimpses of what’s inside.  It’s not unlike addictions, which are largely seen as the problem when they are, in fact, poor solutions to other problems the person is facing.  Often, these are the same kinds of pains that suicidal people struggle with.  (See The Globalization of Addiction, Dreamland, and Chasing the Scream for more about substance use and addiction.)

When we recognize that people see suicide as the solution and they’re the experts on their lives, we can bring to them things that are outside their perspective and experiences that may give them at least a few Alternatives to Suicide.

Book Review-Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients

What we wouldn’t do to be able to classify suicidal risk over someone’s life.  The ability to see when a person is – and isn’t – suicidal would be a great boon to our work to prevent needless deaths.  This is the grand vision to which Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients aspires.  We’re not there now – and we may never get there – but there’s value in continuing to attempt to understand suicide before it claims even one more life.

Most of Those who Died by Suicide Were Mentally Ill

It’s hard to study whether someone who died by suicide was – at the time – afflicted with a diagnoseable mental illness.  The person is no longer around to discuss the situation, and therefore the psychological autopsy process – with all its limitations – must be used.  (See Review of Suicidology, 2000.)  The primary problem with the psychological autopsy approach is that it is subject to the biases of the investigators – and if they believe there should be mental illnesses, they’ll look for it.

DSM-5, the current Diagnostic and Statistical Manual of Mental Disorders published by the American Psychological Association, is frequently referred to as “the book of woe” and is further characterized as leading clinicians to over-pathologize normal responses.  If you’re supposed to find something, and you look in the DSM, you’ll probably find something.

So, the retrospective interviews with family members, friends, and colleagues often led to identified mental illness.  Perhaps the most telling aspect of the results that found mental illness is that the primary finding was alcoholism – what would now be called alcohol use disorder (AUD).  This is telling, because in 2019, 25.8% of people in a general population survey reported having indulged in binge drinking in the preceding month.  This means they’d likely qualify to be diagnosed with at least mild AUD.  In the studies referred to from Suicide Over the Life Cycle, the percentage of patients diagnosed with a primary diagnosis of alcoholism is substantially similar to that number.

Certainly, alcohol use could be considered a mental illness, and it is also correlated with suicide deaths.  However, few would characterize it as a severe mental illness – what people often think of when they believe someone is impacted by a mental illness.  If we lower the bar to any kind of mental impairment, we could perceivably make most people who die by suicide have a mental illness.  It would, however, necessarily include nearly every adult.

The second primary diagnosis in the referenced studies was depression, something that many people in the United States struggle with today.  Again, it’s something that most people would not characterize as a serious mental illness but something that is included when categorizing most people who die by suicide as having a mental illness.

And that’s not all.  The other challenge is in the identification of those who are suicidal.  The approach used was coroner determination, which is known to be quite inaccurate.  It’s entirely possible that a coroner will decide to mark something as a suicide only when they suspect mental illness, thereby biasing the samples.

So, is there research that says most people who died by suicide had a mental illness?  Yes, that’s true.  However, the research is fundamentally flawed in at least two dimensions, and the conclusion that someone had a mental illness might include more of us in the general population than anyone would like.


Let me return to the problem of alcoholism as a factor for suicide risk.  On average a person who has alcoholism who dies by suicide have been alcoholics for 20 years and die at age 47.  It’s hard to separate the impacts of alcoholism from the disorder itself.  We know that alcoholics often have unstable home, professional, and social lives.  Their disordered drinking leads them to lose their jobs, their homes, and their relationships.  These are all substantial factors that lead towards suicide – with or without the introduction of alcohol.

To be clear, it’s not that there isn’t a relationship between alcohol and suicide – there definitively is.  The challenge is that alcohol can induce alcohol myopia whether or not the person is an alcoholic, and it’s difficult to separate the work, home, and social losses from the alcohol use when determining how correlated they are.

Roles and Responsibilities

Durkheim’s assertion that suicide seemed to increase during periods of economic downturn has been well replicated – for men.  Men’s expectations are shaped by society such that their worth is driven by their ability to work and provide for themselves and their families.  Economic downturns obviously make that harder, and it’s easy to accept that men will choose suicide rather than face and address their inability to find work – presuming there is a solution.

Women, on the other hand, are often shown to be more distraught over relational or family-relational issues.  They’re more likely to be influenced by divorce or estrangement than moderate fluctuations in the business cycle.  This seems to be driven by acculturation.  We expect that women will be more focused on family and relationships and disruptions are more impactful.

These are, obviously, stereotypes.  However, both fall into the key category of missed expectations.  We’ll find that people are more likely to die by – or attempt – suicide when their expectations aren’t matched with the results that they’re getting – and that applies to men or women.

On the Same Team and No Suicide Contracts

It’s subtle.  When you insist on a contract with a person, you’re acknowledging the potentially adversarial direction of the relationship.  Contracts are used as instruments to document an agreement – but more frequently, they’re the basis for determination of right and wrong.  When we pressure someone into a contract, we’re acknowledging the very kind of adversarial relationship that we should be avoiding with a suicidal person.  On the surface, asking for a contract that says the other person won’t attempt suicide is pointless, since they’re not likely to think of the contract during a suicidal crisis.  More importantly, what consequences can the contract extract from a dead person?  (The answer is none.)

Rather than a focus on no-suicide contracts – which don’t work – we can do something that will potentially improve our outcomes.  We can find ways to signal that we’re on their team.  We’re there to support them.  We don’t think that suicide is the right answer, but we want to better understand them and help them solve the problems that may make them believe that death is a better option.

Blame Seeking Messages

Often after a suicide death, there’s a rush to figure out who is to blame.  It’s a bad outcome, so someone must have done something wrong.  The problem with this is a belief that, for something bad to happen, then someone must have done something wrong.  We don’t expect there is someone to blame if a tsunami wipes out a village, so why do we believe that there is always someone to blame when someone dies by suicide?  I’m not saying there are never people to be held accountable for malpractice, but this is much rarer than we seem to give credit for.

Seeking the answer to “why” is an unfortunate artifact of our evolution and our desire to predict the future.  Rare events, whatever their cause, are met with skepticism and confusion, since our prediction engines have failed.  (See The Black Swan, The Signal and the Noise, Superforecasting, and Noise for handling rare events.)  We look for someone to blame, so we can incorporate their malfeasance as a part of our models.


Suicide Over the Life Cycle oversimplifies the response to the hopeless person and says, “The clinician should not expect to dissuade patients of their hopelessness; rather the clinician must win the patient’s cooperation to undergo, and stick with, treatment.”  Certainly, there’s no point in developing a direct conflict with a patient.  However, there’s a path between directly disagreeing with the hopelessness that someone feels and basically ignoring it.  In fact, both cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT), the most common treatments, encourage patients to challenge their own thinking and to remove cognitive distortions – with the assistance of the therapist.

Rather than dissuading patients from hopelessness, it may be enough to just try to understand it.  As the research around Motivational Interviewing shows, sometimes listening is all that is needed.

Habitual Errors

Sometimes, the cognitive distortions facing a patient can be identified and addressed.  Habitual errors in thinking are termed “cognitive distortions” by Aaron T. Beck. They include the following:

  • arbitrary inference, drawing a conclusion based on insufficient or even contradictory evidence;
  • selective abstraction, attending to only a portion of relevant information;
  • overgeneralization, abstracting a general rule from a single event and applying it to both related and unrelated events;
  • magnification and minimization, exaggerating or underestimating the magnitude and importance of events;
  • personalization, attributing causality to oneself when several factors contributed to an outcome; and
  • dichotomous thinking, categorizing people and events in absolutistic, black-and-white terms (e.g., good versus bad).

What to Do When a Client Dies by Suicide

When a client dies by suicide, the counselor, therapist, social worker, or coach will feel the loss themselves and need to process these feelings – but they’ll also need to consider how they will engage with the family.  Some will try to minimize contact and pretend that nothing happened even to the point of failing to address the next of kin’s questions and requests.  Suicide Over the Life Cycle makes it clear that this is a bad strategy.

In our own situation, Alex’s social worker elected to not be responsive when we reached out.  That failure to respond was very problematic – enough that there was a cross-agency escalation.  Even if you don’t feel comfortable answering questions, it’s a good idea to be responsive as possible to the family, because you want to avoid becoming adversarial with them.

While we cannot foresee suicide as an outcome in most cases, it’s important that we begin to see Suicide Over the Life Cycle as best we can.

Book Review-The Neurobiology of Suicide: From the Bench to the Clinic

By the late 1990s, a great deal was being learned about the neuroscience of the brain.  Magnetic resonance imaging (MRI) became popular in the 1980s, and it was extended to functional magnetic resonance imaging (fMRI) in 1990, which opened up new doors in learning about not just the structure of the brain but also the patterns of neurological firings.  As we began to learn more about the brain, it became important to share that with the broader clinical community to encourage research-informed care.  The Neurobiology of Suicide: From the Bench to the Clinic, published in 1997, was a step towards that goal.

Adverse Childhood Experiences (ACE)

In 1996 and 1997, the people who would participate in the landmark adverse childhood experiences (ACE) study were just being selected.  The long-term follow-up would continue for years.  However, it’s an understanding of the developing awareness that people with trauma– or even instability – in their childhood would have problems in their adult lives.  (See How Children Succeed for more on the ACE study.)

The language of the book is “chaotic” family situations – the kinds of trauma and instability the ACE study was destined to find later.

Suicidal Behavior Family Clusters

One of the places where the answers get fuzzy is when the book claims that suicidal behavior clusters in families – like so much else in psychiatry.  Here, the evidence proposed is a twins study: the twins who are paternal (coming from one egg) are compared with those that are maternal (coming from two eggs).  The concept is straightforward.  If they came from one egg, then they have the same genes, and therefore we can say that there is a genetic cause to something if both members of a twin pair are affected.

However, as Judith Rich Harris carefully explains in No Two Alike and The Nurture Assumption, there are many other confounding variables that tend to make all twins alike.  The environment that the children are raised in matters.  In other tests, even identical twins diverge in their interests sometimes – and sometimes not.

There seems to be some evidence that genetics play a factor in suicide – but no more than the typical 50% genetics, 40% environment, and 10% unknown that we often see for anything else in psychiatry.  So, it may be true that there are clusters of suicides around family trees, but it’s not necessarily clear whether this is due to genetics, cultural cues – both societal and familial – or something else entirely.

Like many things in suicide research, just because there’s a correlation there is not necessarily a causation.

Low Base Rates

In Rethinking Suicide, Craig Bryan explains why prediction may be a fool’s errand, and that reason is a low base rate.  To be an effective screening tool, it would need to be substantially more precise than any of our existing tools for any mental illness.  It’s like trying to shoot a 9” plate on the Moon – technically possible but very technically challenging.  It’s no surprise, then, that in 1997, it was explained that the tools of the day weren’t very predictive.

Behavioral Intent

The challenge with whether something is – or isn’t – a suicide often hangs on the idea of intent.  Did the person intend to strike the tree with their car, or did something else happen?  It’s incredibly hard to know if someone was truly intending the accident or whether it just happened.  Who is to say it wasn’t texting and driving instead of a willful act?  There is no way to know for sure.  While it’s possible to guess – through a psychological autopsy (see Review of Suicidology, 2000) – that doesn’t mean that the psychological autopsies are foolproof.

Given the very low incidence of people writing suicide notes (<25%), it’s no wonder that the question of intent during accidental circumstances can be so challenging.


The real challenge that was facing researchers in the late 1990s was that the degree of risk that researchers’ institutions were willing to take for suicide research was very low.  This often prohibited the researcher from doing the best science they wanted to do, and instead hamstrung them into research approaches that were less clinically demonstrative for the sake of lowering the risk.

Funding was also a challenge, as other conditions like cancer and AIDS were receiving substantially more funding.

In the end, The Neurobiology of Suicide is a good map of the headwaters of what we were starting to learn about neuroscience and suicide.

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