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Book Review-Life Under Pressure: The Social Roots of Youth Suicide and What to Do About Them

What causes suicide clusters to form?  That’s the fundamental question behind Life Under Pressure: The Social Roots of Youth Suicide and What to Do About Them.  The book follows a community known by the pseudonym of “Poplar Grove.”  It recounts stories and quotes from interviews to understand what has made Poplar Grove such a hot spot for youth suicide – and what can be done about it.

Clustering

Usually, a suicide cluster is two deaths plus an attempt or three deaths in a short period of time in a constrained geographic region.  The real question is what causes them and what can be done to prevent them.  There are several factors that lessen the barrier to suicide for those exposed to one.  First, suicide is brought to mind as an option that may have never been considered before.  Second, the death of someone close necessarily causes grief – and that makes life seem a little less worth living.

But not every suicide death (or any death, for that matter) sets off a suicide cluster – far from it.  While suicide clusters aren’t frequent, they are painful for the people who are left behind and communities they occur in.  Understanding what conditions create or allow clusters to form allows us to design interventions to prevent them – at least in theory.

The Setup

Life under Pressure is a bit repetitive.  It focuses attention to the intense performance pressure and dense social ties of a “must-be-seen as” community as the contributing factors that led to so many youths deciding that death looked better than life.  (See Leadership and Self-Deception for more about “must-be-seen-as.”)

Performance Pressure

Some communities value educational and professional attainment to a degree that they place pressure on their children to be the best, to be involved, and to not show faults.  (See The Years that Matter Most, which was later republished as The Inequality Machine: How College Divides Us, for more.)  The result is that we’ve developed youth with greater anxiety and perfectionism.  (See Perfectionism for more on what it is.)

To be fair, this pressure provides growth opportunities that are needed.  (See Antifragile.)  It can even be argued that peak performers need some degree of pressure.  (See Peak.)  The problem is that this community didn’t create the kind of “air bags” that Robert Putnam describes in Our Kids.  (See also Putnam’s Bowling Alone for background.)

Parents and community members said they were available for youth that needed help – but the youth didn’t believe it, or at least didn’t use it.  They didn’t believe that they were psychologically safe enough to share.  (See The Fearless Organization for more on psychological safety.)  They also didn’t believe that others would or could help.

Dense Social Ties

Generally, we speak of connectedness and social capital in a positive way.  It has protective factors.  (See Analyzing the Social Web for a technical analysis of social ties.)  However, as Richard Hackman explains in Collaborative Intelligence, sometimes teams (his context) have connections and boundaries that are so rigid that they inhibit growth and results.  From Jesuits (see Heroic Leadership) to economics (see Trust), ethics (see How Good People Make Tough Choices), and sociology (see Delinquent Boys), we’ve learned that rigid cultural control of people can have negative consequences, and it sometimes takes real skill to avoid getting wrapped up in them.

Everyone knows everyone else’s business.  That’s the problem.  High performance expectations and dense social ties means that if you admit to a challenge, a limitation, or a fault, everyone will know it in an instant.  This is the driver that makes psychological safety so hard.

Everyone knows that if they admit a problem, everyone will know – and everyone will judge them for it.  Maybe they’ll be overt about it, or maybe they’ll be silent.

Community Pride

There’s a shared ethos of pride and expectations in the community.  They’re all there because the parents wanted to give their children the best chances to succeed.  They’re into athletic excellence as well as academic excellence.  The parents made it far enough in their lives and careers to make it possible for their children to grow up with good schools and support.  They never thought that it would lead to so many with anxiety and so many of their children considering or attempting suicide.  They never saw it coming.

Warning Signs

While the repetitiveness of the book can be frustrating, it’s nothing compared to the promotion of falsehoods.  It says, “To correct another myth, we should address the belief that suicide rarely occurs without warning. There are almost always warning signs. Unfortunately, our society is not very good at recognizing those warning signs and intervening.”  First, if they were dispelling a myth, one would think they’d offer evidence, but no evidence is offered.  Instead, the authors push forward a statement that isn’t based in fact – and is problematic on multiple levels.

The argument is often that, in retrospect, people identify signs.  There are two fundamental problems with this.  First, they’ll claim to see signs that were never present.  Recall-based approaches have been proven faulty repeatedly.  There’s no way to say that what they recall actually happened.  Second, and more importantly, these signs don’t have any predictive value.  Often warning signs include “behavior change.”  The problem is that people change their behaviors all the time – and a vanishingly small number of people are going to attempt suicide because of it.

I have 3+1 signs.  The 3 signs are when they say, “I’m going to die/kill myself/suicide,” “(It doesn’t matter) I’m not going to be here anyway,” and “I want to give you this (prized possession) because I know you like it.”  The +1 is sleep disturbances.  For the first three, we’ve got a clear message we can and should respond to.  For the +1, it’s a reason to check in – and continue checking in.  Sleep challenges lead to cognitive challenges – and cognitive constriction, which can be dangerous.

I’m not suggesting we can’t start a conversation about suicide when we see one of the signs on the numerous “warning signs” lists.  I’m saying we should be starting a conversation about suicide without them.  The warning signs just aren’t predictive of risk in an individual.

The problem isn’t “recognizing.”  The problem is that we’ve included so many signs that they’re meaningless.  If you don’t believe me, you’ll find the evidence at Myth: Every Suicide Attempt Has Warning Signs.  (Direct journal articles and research are linked from this page.)

No Mulligans

In golf, a mulligan is an attempt to do the same shot again.  Live doesn’t have mulligans, but too many parents treat their children like their own personal mulligans.  If they didn’t get the starring role in the high school or college play, their child surely will.  They missed out on an athletic scholarship to college, certainly that won’t happen with their child.  Whatever dream they missed, their child won’t.

The problem is that life isn’t designed to work this way.  They get their shot – and their children should get theirs.  If they force their will on their children, both the parent and the child tend to be disappointed, frustrated, angry, and confused.  It’s not healthy – but it’s something that I see all too often.

School Responses

The school in Poplar Grove was criticized for their responses.  However, even the guide, “After a Suicide: A Toolkit for Schools,” from which the authors draw their perspective isn’t perfect.  There are simple things like treating all deaths the same and ensuring that the suicide isn’t glamorized.  However, as you dig into the guide, you’ll find an inappropriate coupling of mental health to suicide, implying or directly stating that this should be a part of messaging to parents and students.  There is no research support for this approach – and it necessarily further couples and stigmatizes both.

While insisting that all deaths should be handled the same – and they should – the guide continues to prescribe different messaging and approaches for suicide.  The guide itself (and the authors of this book) are inadvertently doing the very thing they’re telling others not to do.

Shaky Ground

Qualitative research is very difficult to get right, and often it suffers from biases.  The questions that are asked (even in structured interviews) are often driven by the perspective of the interviewer.  That’s just a part of the process as we move from qualitative to quantitative research.  However, one can practically hear the rumblings, as statements like, “we are fairly convinced that large, well-attended memorials have unintended negative mental health consequences,” clearly reflect the bias of the authors (as indicated) – but no proof or theory is offered to support these type of statements.

While I can appreciate the delicate nature of interacting with a community in the midst of a suicide cluster, I cannot fathom statements like, “We did not feel it was appropriate for us to attend any of these memorial services or vigils ourselves, so we cannot provide an observational account.”  I liken it to the person who records a video of someone else getting injured rather than rendering assistance.  I see no reason why someone researching how to prevent more death can’t approach an official to ask for permission to listen to the service.  It strikes me that this decision might be based more in fear of the awkward conversation. “How did you know the deceased?”  The answer is simple.  “I didn’t, but I want to prevent others from dying like they did so I’m here to learn from family and friends.  I hope to learn more about him/her.”

There is some good to be learned from pressure.  However, it’s not right to have an entire Life Under Pressure.

Book Review-The Prediction of Suicide

Aaron (Tim) Beck, Harvey Resnik, and Dan Lettieri are the editors of The Prediction of Suicide.  The assembled work brings together the best minds in the prediction of suicide in 1974.  The arguments made then are like the arguments that could be made today.  In the preface, they state, “Despite the voluminous research reports, there is a very flimsy basis of knowledge that can contribute in a scientific sense to the problems of the worker in this field.”  It’s a challenge that hasn’t changed substantially in the fifty years since this publication – but hopefully it’s one that will change soon.

The Process

The point is made that, “Suicide is the end result of a process, not the process itself.”  This belies the problem of prediction and identification.  We speak of the outcome, but even today, we struggle to articulate the pathways that lead to this outcome.  It’s understanding these pathways that provides hope for our ability to do some level of prediction of suicide.

The one differentiation that can be made about the process – even in 1974 – is related to the outcomes.  “But the unsuccessful suicides are no doubt quite different from the successful, and the former cannot be regarded as representative of the latter.”  The categorization is that attempts must be categorically different than deaths, because the outcomes are different.

I think this hides the reality of the randomness to the process.  Silvia Plath arguably wanted to be found and her attempt to be aborted.  (See The Savage God and Suicide and Its Aftermath.)  Even though she eventually died, her process may have been closer to that of an attempter who didn’t die.  In short, while we can presume that there’s a difference between attempts and those who die, we can’t really know.

Zeigarnik

Blume Zeigarnik was a student and colleague of Kurt Lewin.  She noticed an odd thing about the memory of servers.  They could remember orders without writing them down – until they relayed the order to the kitchen.  After that point, they promptly forgot the order.  This led to the discovery of what we call the “Zeigarnik effect,” where uncompleted tasks are held more prominently in memory.

Joseph Subin, in the first chapter, hypothesizes that the Zeigarnik effect may have an influence on attempters, providing some subtle draw towards “completion.”

Call Centers

Suicide call centers are an important part of the overall system of care to try to prevent suicide, but the book notes that “only 4 percent of suicide attempts and even a smaller percent of the eventually successful suicides called suicide prevention centers.”  So, they’re an important part of the overall strategy – even if the overall match to those who make attempts is low.  We see this same sort of calling pattern in 988 today.

The Perception of Control

We often underestimate our need for the feeling of control.  The belief that someone has control and the presence of options has consistently demonstrated a positive effect on mood for people.  We see this in places where there are suicide options for those with terminal illnesses.  The number of people who use the suicide option after having been approved is very low.  (See November of the Soul.)  They’ll go through great lengths to acquire the ability to die by suicide – and simultaneously decide not to use the option.

At its heart is our perceptions of control.  When we feel we have control, we have a greater capacity for self-soothing and down-regulation of fears.

Mental Health Disorders

Mental health disorders are, for the most part, time-limited with or without therapy.  That’s striking, but not totally unexpected, news.  For most of human evolution, mental health disorders have occurred before the introduction of psychotherapies and the like.  This is not to say that mental health assistance is a bad thing – far from it.  Antibiotics, in most cases, merely decrease the time it takes to heal, but we still use them anyway.  Similarly, mental health supports are good things.  But understanding that mental health disorders typically self-resolve can help us to understand how suicidal crisis can also self-resolve.

To be clear, this is not to say that all mental health disorders will self-resolve – they won’t.  However, the argument made by Zubin is that they largely self-resolve.

Actuarial Versus Clinical

One of the big challenge in the prediction of suicide is the difference between aggregating various risk factors to develop a risk score for an individual and the need to sit next to someone and make a decision about whether they are a risk to themselves.  (Ideally, sit next to them rather than across from them, as still often happens – see Motivational Interviewing and Managing Suicidal Risk.)

In the development of actuarial risk, demographics and history are combined into a single score based on previous research and factors that can be identified to raise or lower the risk.  Being an “old white guy” raises one’s risk – my risk.  Other factors are loaded into the assessment to create a score.  However, this score has nothing to do with me personally and everything to do with the statistical abstractions made for groups of people.

Time and time again, we’ve demonstrated that such actuarial risk summarizations have almost no utility in the assessment of individuals.  Compiling the most comprehensive profile still doesn’t yield the ability to predict which individuals are at risk.  The statistical (actuarial) process simply has eliminated all of the distinctiveness in the data and with it the ability to see the risk of individuals.

Later in the volume, Beck states it clearly: “The belief that suicidal behaviors are predictable can be valid only as a belief in principle, not in fact.”

Psychological Autopsy

Even in 1974, the limitations of psychological autopsies was well known.  Alex Pokorny explains the difficulty of discovering intent: “It also appears to require a ‘psychological autopsy,’ which is not practical for general use and which also introduced the possibility of circular reasoning.”  He first identifies the effort and therefore cost of doing psychological autopsies.  They’re time consuming.  They require willing participants of the survivors, which isn’t always the case.  That makes them somewhat impractical for broad use.

The more challenging aspects of psychological autopsies are the problems of retrospective reasoning.  After a determination of suicide is reached (preliminarily), the scales tilt towards that, and there is some bias towards confirmatory evidence.  This is held back by the stigma and extra pain associated with suicide death, but the degree to which one of these forces is more powerful than another is both situational and effectively immeasurable.

We’re left with serious doubts about whether psychological autopsies create a real picture of the person’s mind or whether they create a fiction that roughly fits the facts.  This fiction may help us feel better about understanding – but it does not necessarily create actual understanding.

The Categories

One of the challenges of creating good research on suicide is the need for clear and consistent categories.  The categories proposed are completed suicide (CS), suicide attempt (SA), and suicide ideas (SI).  These are good, broad categories, but they miss some of the nuances and challenging situations.

In particular, non-suicidal self-injury (NSSI) is problematic in this framework.  There is a relationship between NSSI – particularly cutting – and later suicidal behavior, but the narrow and coarse framework proposed here doesn’t connect NSSI to suicide.

Screening

Aaron (Tim) Beck was one of the earliest proponents of finding scales to measure risk.  He was developing what became the first risk screening tools – some of which are still used today because of their efficacy.  However, he states, “Nevertheless, even the best of these produces a very high proportion of false positive errors, that is, cases that are unjustifiably labeled as high suicide risks.”  Later, he continues by saying, “For there is currently no detection scheme that can be set to identify half of the available genuine suicide risks without erroneously identifying along with them a lot of people who are not suicide risks at all.”  He acknowledges that because suicide is a statistically rare (and tragically too common) event, it’s hard to develop tools to identify it.

He argues that, in order to get sufficient sensitivity to detect people who may have suicide in their immediate future, many must be identified and later assessed out of the system.  My “back of the napkin” calculations put the false positive rate at about 300-600 times the number of actual positives based on current tooling.  Despite the insistence on the use of these tools, the behavioral health system can’t cope with the false positives that must be screened out.  Even if these clinical assessments were 100% accurate, the sheer volume of work puts a strain on an already burdened system.  The tragedy is that even clinician assessment is a poor predictor of outcomes, as is explained in The Practical Art of Suicide Assessment.

Predictors and Postdictors

Hindsight is 20-20.  It’s a common cliché that pushes us towards an understanding that we can see things in the past that might have never been identifiable before the event.  We can understand the factors and methods that lead to outcomes only after the kind of careful study and clarity that comes after the event.  One of my great frustrations is with lists of suicidal risks, because they include things that frequently occur, including in a proportion of those who attempt suicide.

Things like a change in mood or behavior is often listed.  The problem is that, when applied to teenagers, this is almost universal – with or without suicide risk.  Also listed are statistics like 95% of people with suicide have a mental illness.  That’s misleading, because a very small percentage of those with mental illness will die by suicide (<5%).

David Lester makes the point that what we call “predictors” are all assessed after-the-fact and therefore should more accurately be called “postdictors.”  They have little predictive value.  They do, however, encourage a great deal of guilt and shame on the part of loved ones who feel that they missed signs that they should have seen.

Infrequency

Chapter after chapter in the book has authors saying that suicide is a statistically rare event and is therefore nearly impossible to predict at an individual level.  George Murphy explains how a statistically good screener would be unacceptable clinically owing to the intersection of statistics and outcomes: “From the numerical standpoint, a prediction of ‘no suicide’ in every case would be highly accurate (1,336/1,350 x 100 = 98.96%). It would also be entirely unacceptable clinically.”

Extending out some basic math approaches, he concludes, “More to the point, the predictive accuracy assumed (80 percent) is far beyond our present capabilities. The population chosen for the example (suicide attempters) is one of relatively high risk, and yet prediction of the infrequent event, suicide, is poor. It would be very much poorer in a population unselected for risk.”  The threshold he used of 80% accuracy exceeds the capacity of our tooling even today, 50 years later.  Screening is still required by accrediting bodies in high – and not so high – risk situations despite our awareness that they simply aren’t effective.

The funniest thing is that the more we pay attention to the details, the more we can recognize that it’s a fool’s errand to believe in The Prediction of Suicide.

Book Review-Suicide and Homicide

Suicide and Homicide: Some Economic, Sociological and Psychological Aspects of Aggression proposes that both suicide and homicide are acts of aggression that flow through different channels based on either external or internal constraints.  There are others who have held – and do hold – this perspective.  Karl Menninger spoke of suicide in Man Against Himself as murder in the 180th degree.  More recently, Thomas Joiner in The Perversion of Virtue highlights the common component of killing in both suicide and homicide.

Aggression as a Consequence of Frustration

There are three theories about where aggression comes from.  Freud’s theory places aggression as an outcome of “Thanatos” – death instinct.  Konrad Lorenz challenged Freud’s perspectives based on his observations of how animals controlled their aggression.  The second theory is that aggression comes from frustration.  The third theory is Albert Bandura’s social learning theory.  He proposes that we learn aggression by seeing it in others.  (See Moral Disengagement – The Cases for more.)

Given Lorenz’ criticism of Freud’s theory and mine of Bandura’s, we’re left with the theory that aggression comes as a result of frustration.  One might conceptualize this as “Nothing else is working (or can work), so I’ll try the risky thing.”  Aggression is risky.  Certainly, at a physical level, one can get hurt while attacking another; but at a societal level, even non-physical attacks can backfire.  One can become labeled as difficult to get along with or problematic.

However, this sense that what is being tried is being blocked or is simply ineffective leads to an escalation through aggression.  We’ve been taught not to back an animal – particularly a wild animal – into a corner, because the behavior that we’ll see out of the animal in those conditions – when they feel as if they have no other options – can be harmful to us.

Business Cycles and Status

Much has been made of how suicide relates to business cycles.  It turns out that when business cycles are down – and things are more challenging – we do tend to see a rise in suicide deaths.  While there is some disagreement on the specific timing, the general relationship is generally well accepted.  Conversely, when the business cycle is at its peak, we tend to see more homicides.

We also see that upper and lower ends of the socioeconomic scale tend to be more and less sensitive.  In the low times of a business cycle, suicides increase in the higher socioeconomic status (SES) more than in the lower.  The theory is that those in the higher socioeconomic status are more greatly impacted.  During the peaks, we tend to see greater homicide rates but initiated by those in a lower SES.

Restraints

The fundamental theory is that weak external restraints drive suicide and strong external constraints drive homicide.  In the case of suicide, those who are most at risk as those who are the most affluent.  In terms of homicide, it occurs mostly in those who are at lower SES and therefore have greater external constraints.

Conceptually, those who have fewer external constraints need to impose more internal constraints to function.  If these internal constraints become too tight or difficult, the aggression felt is self-directed.

Perfectionism

The internal constraints that drive suicide may come in the form of perfectionism and the constant failure to meet impossible standards.  (See Perfectionism.)  It could be that we’ve become exhausted on our way to peak performance, realizing that we’ll never reach the goals we set for ourselves.  (See Peak.)  Even in the general form of maximizing rather than satisficing, we know that we’ll be less happy.  (See The Paradox of Choice.)

These are the kinds of constraints that we can impose on ourselves.  It’s not the outside world setting our standards.  It’s our own drive and determination that sets goals that we can’t meet and therefore suicide is a concern.

Social Ties that Bind

Social ties and strong communities are important protectors against suicide that may function in part due to their strong social conformity bond.  Robert Putnam described the erosion of social capital in Bowling Alone.  He later revisited how the decline of social capital wasn’t occurring evenly, with upper-middle class families finding ways to work together and insulate their children from some of the challenges of the world.  (See Our Kids.)

Perhaps if we pay attention to what and who binds us, we’ll realize how little difference there is between Suicide and Homicide.

Book Review-Attachment in Adults: Clinical and Developmental Perspectives

The attachment system that John Bowlby first theorized has spawned a great deal of research and knowledge (in part due to Mary Ainsworth’s contributions).  Attachment in Adults: Clinical and Developmental Perspectives shares some of the interesting and intriguing results of this continued research.

Multi-Generational

One of the more confusing results of the continued research is how a parent’s – particularly a mother’s – attachment style can influence the attachment style of their children.  Securely attached mothers tend to produce securely attached infants.  In short, parents can help their children’s lifelong trajectory by focusing on their own mental wellness.

Another confusing corollary is that children who are securely attached have more complex and mature representation of their parents.  They seem to understand the nuances and details of how the parents will interact in ways that their insecure counterparts do not.

Timing

There’s an odd thing about the timing of attachment styles.  First, attachment styles seem to appear between 9 and 18 months after birth – the same timeframe as object permanence.  In other words, from the very first moments we can recognize something not in our sight – something for which we have a mental model – we start working on attachments.

As adults, the research seems to indicate that a relationship with a securely attached individual has the effect of moving an insecurely attached partner towards secure attachment – over a two-year period.  It seems as if there’s an importance to the period of time that the secure relationship is available.

Individualism

The challenges with the Western/American view of rugged individualism has surfaced before.  I’ve addressed the challenges with the illusion in my reviews of How Good People Make Tough ChoicesHumble Inquiry, and Our Kids.  However, as the power of attachment to shape our lives for good or bad is brought to the forefront, the degree to which we believe that we’re able to survive as an individual seems even more of a pernicious delusion.  Whether it’s the data from Loneliness or the research around attachment, we know that we can’t live life alone.

Fathers Be Good to Your Daughters

John Mayer’s song, Daughters, includes the lyrics, “Fathers be good to your daughters / Daughters will love like you do.”  Strangely, research has found that the best predictor of a daughter’s emotional security in a love relationship is a close emotional bond with her father.  The degree of impact that fathers have in this regard is stunning given the relatively low amount of time that fathers spend directly interacting with their daughters.

Approval Competition

In some families, approval is a scarce resource that must be saved.  It may be that there is only one person who is receiving approval at one time.  There’s a favorite child.  The problem with this is that it develops anxiety in the children who feel that they must earn love, acceptance, and approval.  They believe that they’re one mistake away from losing their status within the family, with disastrous consequences to their long-term relationships.

Network Maps

If you ask people to map out their important relationships, they’ll often include people who are deceased.  As mentioned in New Models of Bereavement Theory and Treatment, people develop internal representations for people that are no longer with them.  It’s a plausible explanation that they still feel that person’s presence through the internalized concept of them.  It could also be that they just aren’t thinking clearly.  Either way, it signals that there’s more to our world than we realize and a great role for Attachment in Adults to play.

Book Review-The Joy of Connections: 100 Ways to Beat Loneliness and Live a Happier and More Meaningful Life

Dr. Ruth is all most people need to hear to know exactly who we’re talking about.  In The Joy of Connections: 100 Ways to Beat Loneliness and Live a Happier and More Meaningful Life, Dr. Ruth Westheimer shares her direct style of tackling the problem of loneliness.  Dr. Ruth was a sensation when she started talking directly about sexual needs and fulfilment on radio and television in the 1980s.  In this book, the elderly (now recently departed) Dr. Ruth shares her loneliness as a child and after the passing of her (third, lifelong) husband.

Quality, not Quantity

Dr. Ruth explains that loneliness is about the lack of quality connections not the quantity.  It’s not a competition of Facebook friends or LinkedIn connections.  What matters, in her opinion, is having a few quality connections that help you believe that people see you and understand you.  This echoes the insights of Sherry Turkle in Alone Together and Jonathan Haidt in The Anxious Generation.  It’s who you can be open and honest with.

Sleeping with Loneliness

A unique quote from Dr. Ruth is, “I’ve been sleeping with loneliness my entire life.”  From that context, loneliness was a companion.  It’s a feeling that was relatively persistent.  It started with the German Nazi party and the Holocaust, when she was shipped away by her mother (her father had already been taken) to protect her from the atrocities that were befalling Jews at the time.  Traveling without a companion couldn’t help but get the loneliness ball rolling.  While she grew up in a group home, her fellow refugees didn’t quiet the longing that had already started to pervade her soul.

She quotes from her diary on July 12, 1945: “Above all, I’m longing for a friend.”  And the following day, “I live with 150 people – and I’m alone.”  These quotes help to spark the understanding that loneliness – the feeling – is different than being without other people.

Love

One could expect that the conversation about love is going to come up in a book by Dr. Ruth – however, it’s not what you think.  She starts by recognizing that there’s an absolute need for self-love.  Until you can learn to love yourself, you can’t fully accept others’ love of you.  (See also Compassion and Self-Hate.)  She admits that learning to love herself took time.  It took time to realize not only could she love herself but that she was worthy of others’ love as well.

It’s a Numbers Game

On the one hand, loneliness isn’t about the quantity of connections – but that doesn’t mean that it’s still not, in some respects, a numbers game.  You don’t need many connections, but you’re going to need to make a lot of connections to find out which ones you can really count on when it’s important.  You must “kiss a lot of frogs to find a prince.”  It’s easy to get discouraged in the process if you don’t seem to be finding those solid people who will be your precious few.  The unfortunate reality is that it’s all about probabilities.

Turning friends into good friends, it seems, is also a numbers game.  Dr. Ruth quotes a study by Dr. Jeffrey Hall, who claims that it takes 200 hours over 6 weeks to turn a friend into a best friend.  I don’t believe it’s quite that formulaic – but definitely it takes time to build relationships that will survive over the long term.

What About Me?

In a world that sells the idea that you must be connected to be real, valid, and included, it’s hard to accept that for a time you’re not connected with a romantic relationship.  It’s hard to accept that you’re going through a period of estrangement with your family.  It’s hard to feel like your best friends are so far away.  It’s easy to wonder, “What about me?”  It’s easy to think that we’re excluded from the rest of the world – but that’s not true.  Dr. Ruth calls us to recognize that there will be a time when we will experience The Joy of Connections.

Book Review-A Biography of Loneliness: The History of an Emotion

When there’s a famous person that we’re interested in, we’ll read a biography.  However, A Biography of Loneliness: The History of an Emotion isn’t about a person.  It’s about an emotion that rose to prominence over the last several decades to the point where the US Surgeon General calls it an epidemic.  It’s important enough that it deserves more discovery.  I’d already read Loneliness by John Cacioppo, and it was a wonderful book.  It seemed like some perspective from across the pond would add depth to my understanding – and it did.

Feeling Misunderstood, Estranged, and Rejected

There are many definitions for loneliness, but the experience of loneliness is described consistently.  It’s the feeling that someone is disconnected from the rest of humanity.  It’s a feeling that somehow a great gulf exists between us and others.  It can bloom from feeling as though others don’t understand us.  It can be triggered by a specific misunderstanding but more frequently is just a general sense that we’re out of alignment with the rest of humanity.

Sometimes, this sense of disconnection is founded in concrete reality.  It can be that we’ve become estranged from some part of our family.  (See Fault Lines.)  While this is painful, it’s helpful to know that it’s all too common.  Even Fred Rogers’ son didn’t speak with him for a while.  (See Life’s Journeys According to Mister Rogers.)

Another cause for a sense of loneliness – and disconnection from others – is the specific case where we’ve been rejected by another, whether it was a simple refusal to join us for an event or a more serious rejection like a breakup or divorce.  While, intellectually, we may recognize that this is one person (or perhaps a few people) and not the entire world, it doesn’t feel that way.  Martin Seligman explains how things can feel personal, pervasive, and persistent in The Hope Circuit.  It certainly can feel that way even if the rejection is a trivial one.

The Only Thing We Have to Fear is Fear Itself

Franklin D. Roosevelt’s inaugural address highlighted the fact that fear can be a problem itself.  This is particularly true with loneliness, because fear changes the way we behave.  Because of that, we often make choices that lead us toward loneliness.  We pull ourselves into our shells like scared turtles, and by eliminating opportunities to interact with others, we intensify our feelings of loneliness.

Loneliness Visits All

If you find someone who says that they’ve never felt lonely, they’re probably lying.  (See Telling Lies.)  Loneliness – the feeling of disconnection – is a part of the human condition.  Everyone feels it.  The difference isn’t whether someone does or doesn’t feel lonely.  The real concern is when the feeling becomes more consistent, persistent, or pervasive.  While my loneliness and your loneliness may not line up in time or by contextual situation, we can understand the feeling.

Oneness, Solitude, and Loneliness

Thus far in this review, I’ve focused on the feeling that loneliness creates, because it’s the key aspect that separates two other conditions, which are often co-mingled with loneliness.  The way that you can distinguish the state of being the only person in an area or a sense of solitude from loneliness is the emotional impact.  In fact, if we were to arrange them on a continuum, where loneliness is the most distressful, oneness would be neutral.  It’s a relatively benign observation of the count of people.  The other end would be held down by solitude with the idea that this is oneness that is desired.

As an introvert, I crave time when I’m alone.  (See Quiet for more on introverts.)  I crave the chance to read and write uninterrupted.  This isn’t to say that I don’t like time with my family – I need that, too.  The point, however, is there are times when I want to be in a state of oneness.

Accountability Separates Online and Offline

When we start looking at how society has changed and the impact on loneliness, we cannot ignore the transformation that information technology and telecommunications have fueled.  (See also The Upswing and The Anxious Generation for more on these changes.)  While we can talk about the specific technologies and their specific impacts, there’s been a subtle shift that has made a big difference sitting below the increased opportunities the technology brings.

Take a trip back in time a little over a century ago.  Travel is mostly by horse-drawn carriage, with railroad becoming an option for the more affluent.  Rather than the population being concentrated in large cities, it was spread out in small hamlets and villages.  Imagine you’re born into a little village.  You’ll know everyone, and they’ll know you.

Structurally, your relationships will be different than they are today.  If you don’t like someone, you can’t really move away.  You can’t afford to be mean to them or to alienate them.  You and all your neighbors know you need each other, even if you don’t like or even fully trust one another.

Today, we’re more mobile.  We leave the city we grew up in to take a job in another state.  We move when we don’t like our neighbors.  We find ways to build a new set of friends and discard the friends we grew up with.  The ease of finding and making new friends has made us less concerned about offending others.

It’s also made us less accountable.  Instead of meeting our commitments, we collectively think that no one will notice.  We can simply focus on ourselves rather than focusing on our integrity and character.

Even if we stand against these values, others may not.  (I’ve been in my home for over 20 years in one of the three places that I grew up as a child.)  We’re living in a world where people discard others because of perceived injustices without a second thought.  (For more, see The Art of Community.)

The Fear of Social Death

Our fear of death is well researched.  (See The Denial of Death and The Worm at the Core.)  The proposal is made in this book is that our fear of loneliness may be a result of a fear of social death.  We may feel that we’ll no longer be connected and “alive” to other humans.  It’s this fear that drives loneliness.

Rituals

Rituals operate around us at every level.  Joseph Campbell explains in The Power of Myth how rituals connect stories.  In Anthro-Vision, Gillian Tett explains how rituals are connected with cultures.  John and Julie Gottman explain in The Relationship Cure how critical positive rituals can be to relational health.  In The Rites of Passage, Arnold van Gennep explains how rituals help us feel connected to history and each other.

If we’re struggling with loneliness, one place to look for a fix is to find rituals that we can find comfort and connection in.  Maybe a good first ritual is one where you grab a drink and curl up to read a good book like A Biography of Loneliness.

Book Review-Marital Separation

It started with work on what happens when one member of a couple dies.  What’s the process by which the bereaved person reconstructs their life?  This led Robert Weiss to a broader study of all Marital Separation, inclusive of divorce.  (For more on divorce, see the book, Divorce.)  Weiss’ focus remained on the transformations that the bereaved make to cope with their new circumstances.

Social Responsibility

The way that we see the institution of marriage varies by society, culture, and time.  Our beliefs about social structures and love are subject to similar kinds of forces.  (See Anatomy of Love for more.)  Arranged marriages are all but gone in America though they remain the standard in other parts of the world.  In America, we believe that we should marry for love.  Marriage is about two people who fall madly in love and decide that they want to make the commitment to sustain that love over a lifetime – at least in theory.

This perspective is one of individual desires and economic advancement.  It’s not a social responsibility.  These are the words that Weiss uses, insisting that we’ve de-sacralized marriage.  He believes that the no-fault divorce has allowed us an easy escape from a difficult patch in a marriage.  The data on divorce rates dramatically increased following the acceptance of no-fault divorce.

His point is that individuals are so focused on the impact to their happiness that they don’t recognize and account for the impact that their decisions to get – and stay – married has on others.

When it Breaks

Weiss starts with separations and the disruption this causes to both parties and to any children that may be a part of the marriage.  His data points to half of the separations ending in divorce.  Similar concerns can be raised when one member of the couple encounters a life-threatening disease and dies.  There’s expected impairment of reason, rationale, and logic.  (One that attorneys lament when they’re engaged.)  This is, of course, trauma.  (See Trauma and Recovery for more on trauma.)

Regardless of the cause, the remaining parties develop their own accounts – their own stories – about what transpired that has left them decoupled.  James Pennebaker’s research illuminates the need for creating our own narratives of every serious situation that we survive, particularly traumas.  (See Opening Up.)

What is interesting about these accounts for a couple that is separated or divorced is that they often agree on the things that happened but differ in their interpretation of them.  The meaning that each party creates around the actual things that happened can be quite radically different.

The Ties

Weiss speaks of many times when couples would separate or divorce only to come back together for support – or sexual relationships.  It’s hard to separate permanently from someone who you’ve been so close to, so reconnections are common.  In some cases, Weiss reports that people speak of their ability to be friends or sexual partners with their former spouse – even if they know they can’t be husband and wife.

There is one exception to this which is if the person is understood to become intrinsically different.  That is, the person they are now is separate and distinct from the person that you fell in love with and the person with whom you have shared a relationship.  This can be because of extreme behavior or a substantial betrayal, which leaves you wondering how much you knew about the other person.

Rage

Anger is disappointment directed.  (See Destructive Emotions.)  Rage is often when you have a need that’s not being met.  Rage between separated parties often occurs if there’s an unfulfilled need that continues.  The need can be material or financial, emotional, or sexual.  These unmet needs create more and more pressure on the individual until they’re no longer able to be contained and they erupt as rage.

Family of Origin

While not the language Weiss uses, more contemporary language calls the family you grew up in your “family of origin.”  With some tragic exceptions, these are the people that one can depend upon when they’re in need.  There’s an unwritten expectation that you can count on any member of your family to respond to your request for help.  Despite this, most of us are guarded with our families.

There are topics that are off limits.  You can’t discuss religion with Aunt Mary.  Don’t get Uncle Ralph started about politics.  Don’t talk about your concern for Tibet with your mother.  Those are not particularly difficult, because they’re not personal.  However, stories are told all the time by people who are openly gay – except with their families.

The truth is that we are careful when it comes to letting our families into our confidence for fear that whatever we share will come back to haunt us – repeatedly.

Friend Fallout

Much is made about the division of assets in a divorce.  There’s the concern for who gets the house, the cars, the furniture and so on.  Little is said, however, about how friends tend to divide themselves between the couple, choosing the husband, the wife, or neither.  In my own divorce, there were some friends that chose sides and others who chose to separate from both of us.  It’s as if they believed that divorce was contagious, or, perhaps more likely, they decided that we were both bad because of the divorce.

Even when friends stand by you, it’s often the case when you can feel out of place, because the things you did before were primarily as couples – and that no longer matches your status, so you’re inadvertently not invited, or you feel out of place when you are.  Ultimately, the decision to stop being a couple can have dramatic impacts on friends as well.

Guilt and Shame

One of the barriers to being able to effectively support the children involved is the guilt over a divorce.  One – or both – of the couple feel as if they’re responsible for the divorce, and as a result, they may not be able to effectively navigate the role of parent in providing support and discipline.  (See The Psychology of Not Holding Children Accountable.)  They may find themselves barely to accept themselves, and a small rejection by the children may set off waves of self-doubt and remorse that immobilizes them.

Shame, guilt’s evil cousin, expands from just that they’ve committed a bad act and instead associates that they are bad.  The absolute of “divorce is bad” becomes a permanent stain on them.  The result is they’re so focused on trying to cleanse their own guilt that they barely notice what the children need of them.

Recovery

The good news is that the effects of marital separation aren’t forever.  Weiss suggests that the typical recovery is two to four years, with the average being closer to four than two.  In my own experience, the time can vary widely outside of this range depending upon the work the person has done beforehand and the work they need to do afterwards.

There are ways that people can prepare – even while working hard to preserve their marriage.  However, sometimes there’s nothing that can be done to prevent Marital Separation.

Book Review-Death and Bereavement

It cannot be escaped.  Death will come for each of us, and, invariably, it will come for some of those we love before it comes for us.  That’s why Death and Bereavement is an essential topic.  We’re not going to avoid it, so we should be prepared.

When Death Beckons

There’s a great deal of turmoil over the idea of suicide for those who are terminally ill and in pain.  I certainly understand the desire to not encourage suicide, but I also recognize there may be appropriate times to allow this option.  (See Undoing Suicidism and Final Exit.)  It’s hard to argue against the idea that someone in pain should be allowed to end their suffering.  Similarly, shouldn’t we allow people to die if they’ve become a burden on their friends and families?  The ethical issues are tricky to be sure, but not having an option seems cruel.

Death Prediction

We have certain expectations about the world that allow us to predict the future and therefore feel safe.  (See The Righteous Mind and Mindreading.)  Sometimes, our predictions and expectations come into question, and that can cause a crisis.  When we see deaths in the elderly, we expect that we’re not the name on death’s list.  We can safely ignore it for a bit longer.  (See The Denial of Death and The Worm at the Core for more.)  However, when someone younger than us dies, we recognize that death isn’t working as it should.  We have a violated expectancy (using the words of Gary Klein in Sources of Power).  That violated expectancy causes us to reevaluate our situation.

Bereavement Overload

Even when death is behaving as expected, it can still be overwhelming.  Elders discover that the death of their family and friends comes at a pace that exceeds their capacity to cope.  Certainly, death is expected, but the frequency can be challenging.  Too many changes to process in too short of a time.

This often leads elders to seek solace from the younger professionals that they interact with, but those professionals often feel unprepared to support the elders, having minimal (if any) training and not enough life experience to impart wisdom.

The Grand Rounds Illusion

The powers of medicine to improve and prolong life are quite impressive, and it’s easy for professionals coming up in the field to expect that medicine can solve any problem.  They believe, naively, that doctors can solve any problem.  It’s not long after contact with the real world that the cracks begin to appear and the illusion breaks.  The resulting disappointment in medicine can leak out in every direction, with doctors frustrated at nurses and nurses frustrated with doctors.

It can even sour the relationship with a patient – or patients in general.  A nurse or doctor may feel guilty that they cannot solve the patient’s problem.  They may even be angry with the patient for dying, because this makes them feel helpless and ineffectual.  It’s hard to separate these feelings that come as a result of trying to help – and occasionally failing.  It’s not their fault, but we want to find someone to blame.

If Love, Then Sorrow

Saying that the pain and sorrow you feel is a signal of the love that you felt for them isn’t any solace in the moment.  However, as it adds to our understanding, we should expect that there will be sorrow any time there is love.  We should expect that the moment of death and the surrounding times preceding and following the death should be filled with sorrow.  To expect something else is to deny our humanity, our ability to love, and our need to grieve.

Sympathy and Empathy

Too many people receive sympathy at the death of a loved one when what they really need is empathy.  Sympathy is “Sucks to be you” where empathy is “I understand this about you.”  One separates, and the other connects.  What we need most during bereavement are people who are connecting with us, since an important relationship has just crossed to a place without any connection.  (See I Thought It Was Just Me (But It Isn’t) for more.)

Abandonment

It’s natural to believe that the deceased abandoned us.  This is particularly true when the death is by suicide.  We wonder how they could leave us here alone.  (See Loneliness.)  However, sometimes the loneliness that we feel – that sense that no one cares – is a tragic illusion.  Imagine the tragedy of having a funeral for a child.  Heap on top of that a sense that no one came.  In one of the stories that was recounted, a father felt abandoned by his community, because people didn’t come to the funeral or visit him afterwards.  His perception of the events was different than the factual record of many people at the funeral and a relatively constant stream of people visiting with him for months.

Ashamed of Death

For many, as Alvarez says in The Savage God, death is more taboo and less discussed today than sex was during the Victorian era.  That represents a problem if we want to be able to work through our fears about death and confront them.  When adults are ashamed to speak of death, then children know that it should not dare cross their lips.  They’ll have to bury any fears and concerns about death to prevent accidentally crossing a cultural line that children aren’t allowed to cross.  It’s only through transparent conversations that we can remove the stigma.  (See Stigma for more.)  Ultimately, we want to be as open as possible about Death and Bereavement.

Book Review-Handbook of Bereavement: Theory, Research, and Intervention

“Bereavement is the objective situation of having lost someone significant; grief is the emotional response to one’s loss; and mourning denotes the actions and manner of expressing grief, which often reflect the mourning practices of one’s culture.”  So start my notes from Handbook of Bereavement: Theory, Research, and Intervention.  Like many of the topics that I read about, bereavement isn’t “mainstream.”  However, it’s important for all of us, because we know for certain that death will call on those we love and on us one day.  (See The Denial of Death and The Worm at the Core for more about our thoughts of death.)  What if there were secrets to how we grieve that would make it easier, shorter, and less painful?

A Rainbow of Reactions

Reactions to the death of someone you love varies.  Some people find themselves sobbing endlessly on the floor, unable to get up or even make their way to a comfortable bed or chair.  Others, in somber tone, push forward through the hours, days, weeks, months, and sometimes years of grief.  There’s no one way to grieve or bereave.  There are ways that last shorter – and longer.  There are ways that are more – and less – disruptive to life, beyond the disruption of the loss of the person.

In short, while there are many ways to be bereaved, some of them are less painful.  That isn’t to say someone should try to hide or unnaturally manipulate themselves into the belief that they’re doing better than they are.  Instead, there’s a desire to discover what makes it easier for people to cope with their loss.  The goal is to alleviate unnecessary suffering, not stifle the natural healing process.

Stages of Grief

In addition to the well-known stage model of grief from Kubler-Ross, many others have proposed staged models of grief.  (See On Death and Dying and Finding Meaning for more.)  I cautioned that many people don’t read carefully enough to understand that the stages aren’t always exactly linear and aren’t experienced in the same way while reviewing The Grief Recovery HandbookHandbook of Bereavement echoes this point, insisting that people not take any staged model too literally while exposing other scholars who have proposed staged models.

An important point raised is that, just like any trauma, most bereaved never totally resolve their grief.  It changes, but it never fully goes away.  (See Posttraumatic Growth for more.)

Bereavement as a Special Kind of Trauma

One can get lost in the study of bereavement and grief and get so focused on the details that they fail to appreciate that the broader study of trauma has a lot to offer.  Psychological trauma is a temporarily overwhelming event – which anyone who has lost someone close to them can identify with.  (See Trauma and Recovery for more on this definition.)

The broader study of trauma helps us to understand the psychological defenses of compartmentalization and dissociation.  (See Traumatic Stress and Trauma Therapy and Clinical Practice for more on both.)

Relationship Changes

When someone we love dies, there are obvious relationship changes.  They’re no longer physically present.  However, there are also psychological relational changes.  First, we tend to idealize the person.  We forget about the fights and remember the good things about them.  This is one of the reasons for the struggles in second marriages of widows and widowers.  Their new love feels as if they can measure up.  In some ways, they’re right.  They’re competing with an ideal image that has been stripped of its frustrations and problems.

Second, we tend to internalize the other person – we create an internal representation of the person with whom we “consult” as though they were still physically with us.  This representation of the person is not the same – but it is also a way we keep them with us even long after their death.

Saying the Wrong Thing

Many people in the community, even family members and close friends, tend to isolate the grieving person for fear of saying the wrong thing.  Somehow, they don’t see that the act of isolation is the worst part of losing someone, and their movement away exacerbates the problem.  (See Loneliness for more.)  It’s possible that someone will say something that causes the grieving person to experience more of their grief – but that doesn’t necessarily mean it’s a bad thing.  It can be that those emotions needed to be expressed.

In general, there’s not something that can be said that will make the grief worse – at least unintentionally.  The fear is largely unfounded.  However, that doesn’t change the behavior.  It can be someone’s discomfort with grief and emotion that causes the avoidance more than their concern for the grieving.

There is one well-intentioned phrase that won’t likely cause harm – but isn’t helpful.  That is, “I know exactly how you feel.”  We can’t ever know “exactly” how someone else feels.  What we can know is some of what someone else is feeling.  The framework we recommend in our Empathetic Conversations course is the definition of empathy, which is “I understand this about you.”  In other words, “I know what it was like for me to lose a spouse” is a better response, because it recognizes your limitations in understanding.

Schema of the World

In Efficiency in Learning, we were introduced to an explanation for how we can operate in a complex world with such limited brains.  The schemas that we build about the world and its parts allow us to simplify things, so we don’t have to consider all the details all at once.  Learning these schemas allows us to be effective in a world that’s too complex for us to really understand everything.  (See Focused, Fast, and Flexible.)  Gary Klein in Sources of Power explains that these mental models allow us to make better decisions – his recognition primed decisions.  When we lose someone, our schemas of the world must change to accommodate the new conditions – and this can be a difficult and overwhelming process.

In my review of The Body Keeps the Score, I discussed trauma in the context of a temporarily overwhelming event and how this shuts down our ability to process the event.  (See also Opening Up, In an Unspoken Voice, and Trauma Treatment.)  I also connected it to the fact that our sense of consciousness is fundamentally a prediction engine designed to keep us safe.  (See Mindreading.)  By predicting what will happen, we can avoid bad circumstances and live longer.  (See The Selfish Gene, The Evolution of Cooperation, and SuperCooperators for how evolution might have developed consciousness as a protective factor.)

Magical Properties

Sometimes bereavement has an added challenge of shame or guilt.  A child who was angry at a parent shortly before their death may believe that their anger resulted in their parent’s death.  Similarly, a child who had misbehaved may view the parent’s death as a punishment for their misdeeds.  One of Erik Erikson’s stages of development is intuitive vs. guilt and involves magical thinking.  (See Childhood and Society.)  However, adults can have various forms of magical thinking related to death.

Certainly, there are desires for the person who has died to come back, even if adults know that isn’t possible.

Constructive Thinking Inventory

Constructive thinking is defined as the ability to solve problems in living at a minimal cost in stress.  In other words, it is the ability to live with minimal stress.  The Constructive Thinking Inventory focuses on areas of emotional coping, behavioral coping, categorical thinking, superstitious thinking, naïve optimism, and negative thinking.  Taken as a whole package, this inventory touches on many of the key factors that lead to the kind of destructive thought spirals that were discussed in Capture.

Many of the things measured are also directly addressed by works today.  Negative thinking is squarely tackled by Hardwiring Happiness.  Naïve optimism is addressed by Bright-sided.  Emotional coping is addressed by many works, including Happiness.

Grief Work

The stark statement is, “Our results did not unequivocally support the grief work hypothesis. Widows who avoided confronting their loss did not differ in their depressive or somatic symptomatology from widows who worked through their grief.”  However, it can be that the construct for grief work isn’t right.  The authors aren’t clear what “grief work” means in this context.  It could mean forced processing before the person is ready – which would obviously not be helpful.  It could be expected (but not forced) work – which is also not helpful.  Grief work, done properly, goes at the pace of the grieving person.  They’re exposed to the right amount of re-exposure, awareness, and work to match their capacity.

The follow up is that those who overly distract from or overly control emotions don’t have as good of an adjustment as those who were less controlled.

The Walking Dead

Some bereaved describe themselves as the walking dead.  The idea is that they’re hollow or have died inside due to the psychological trauma of losing someone.  They feel as if their spark and life is gone.  (See Acedia & Me and The Noonday Demon for more on depression.)

There’s no one “cure” for this condition.  There will be some improvement as time passes, but it’s definitely a concern and one of the reasons why suicide is so high following the death of a loved one.  Loss and pain are expected, but permanent damage should not be.

Death of a Way of Life

Sometimes, it’s not just the loss of the person or person’s that you’re reeling from.  Sometimes, the issues are deeper.  Not only is there the loss to contend with, but often it changes the entire way of life.  A father dies, and the mother needs to take a job outside the house – or the new finances drive changes in what the family can do.  Sometimes, the loss of parents means a move.

In the case of spouses, it changes status from married to widow or widower.  For children losing their parents, they’re permanently connected to the label of orphan.  We can’t untangle the trauma of dealing with the loss and the trauma of having your life upended – nor should we try.

Autonomous Identity

What we must disentangle is our identity as it relates to the other person.  Losing a spouse means moving from couple to individual again.  Ultimately, we need to decide who we are now that the death has occurred.  We can’t go back to our old ways or identity.  Parents and grandparents, spouses and siblings, even children and grandchildren may die before us, starting the bereavement process.  Unlike life, luckily there’s a Handbook of Bereavement.

Book Review-Critical Incident Stress Management, 2e

While sufficiently discredited by research, many first responding organizations continue to use Critical Incident Stress Management (CISM) as a part of their strategy for employee wellness, particularly after a big event or a mass casualty.  I’ve not made it a secret that I think CISM is harmful (which is consistent with research).  I most thoroughly discussed some of the problems in my review of Opening Up.  One could easily wonder why I read this book.  The answer has to do with intentionally trying to give it a chance – to extract some of the good things from the approaches.  I found a few nuggets, but it was hard to find the things that are good and should be a part of any trauma response program.

Take Two

Before I continue, I should say that I read another book about CISM, titled CISM: Group Crisis Intervention, that was so bad I couldn’t find enough to write a separate review for it.  I share this here to reinforce the statement that I’m trying to find value.

Emotional First Aid

Crisis intervention is sometimes considered emotional first aid.  The analogy breaks down pretty quickly.  The direct quote from the book is, “Urgent and acute emotional ‘first aid’ designed to stabilize and reduce symptoms of distress, while assisting the person in crisis to return to a state of adaptive functioning.”  The problematic part of this statement is the “in crisis to return to a state of adaptive functioning.”  It’s problematic, because it treats the person as if they’re misbehaving machine that just must be patched up long enough to get through the crisis.  It ignores the ways that we know humans respond.

Certainly, for a non-zero number of people, they’ll encounter a crisis, and they’ll be unable to continue.  However, this is a rare case in general and particularly in the first responder communities where CISM is still used.  It’s more likely that our automatic defenses will kick in – at least in the short term.

As humans, we have the ability to compartmentalize trauma so that we can remain functional by temporarily blocking out information related to the trauma.  (See Trauma Therapy and Clinical Practice.)  If that fails, the second-line defense of detachment makes it seem as if the trauma didn’t happen to us – or to the people we care the most about.  It’s like we’re watching from above or outside of the situation.  (See In an Unspoken Voice.)

At some point, either when our defenses have been exhausted, or a relative degree of safety is encountered, we’ll attempt to process the trauma and convert it from an implicit memory to an explicit memory.  This happens mostly during REM sleep.  (See Trauma and Memory for more.)

So, fundamentally, the premise that we’re patching someone up in situ (in the crisis or in the moment) is inconsistent with how we operate as humans (in most cases).

Immediacy, Proximity, and Expectancy

Everly and Mitchell refer back to a 1947 book, titled War Stress and Neurotic Illness.  They explain that the authors believe the key to crisis response are immediacy, proximity, and expectancy.  The problem is that the three of these are expressions of a single belief that the person will be supported.  In The Psychology of Hope, Rick Snyder explains the need for willpower and waypower for the cognitive process of hope.  However, when you consider Richard Lazarus’ work in Emotion and Adaptation or Lisa Feldman Barrett’s work in How Emotions Are Made, one realizes that there are expectations of how support will be received by others that influence the way that events are processed.

In short, the authors of War Stress and Neurotic Illness can be forgiven for not recognizing their articulation is about external expectancies of support.  In reviewing the subsequent research, it should be obvious that it’s about the belief that help will be provided.

Mandates

Everly and Mitchell claim that the US Air Force required “CISM-oriented” crisis response programs on all bases, but the cited AF144 153 doesn’t actually say this.  It does indicate that the Air Force needs to be able to care for personnel involved in a crisis – but that’s different.  They similarly claim that the US Coast Guard requires CISM teams via Commandant Instruction 1754.3.  It actually says they need to support personnel when they encounter stress – but it doesn’t specify the program or approach.

I think that’s part of my challenge with CISM: the statements are almost – but not quite – true.

Pennebaker

James Pennebaker has been kind enough to answer some questions about his work after my review of his book, Opening Up.  Everly and Mitchell refer to his work as the authority. That’s why the disconnect between what CISM is and what he recommends is so striking to me.  Pennebaker’s work calls out the need to develop a narrative in a safe way.  Specifically, his research showed a written narrative that could be destroyed without anyone seeing it was best.  This has no place in CISM as defined.

In personal communications with Pennebaker, he expressed some level of surprise that CISM was still in use after the research that had been done that indicated some degree of hazard.

The Core Components

Table 1.2 of the book is reproduced below, as it is the most succinct version of the overall program.

INTERVENTION TIMING ACTIVATION GOALS FORMAT
1. Pre-crisis preparation Pre-crisis phase Anticipation of crisis Set expectations. Improve coping. Groups/orgs.
2. Individual crisis intervention (1:1) Anytime. Anywhere. Symptom driven. Symptom mitigation.

Return to function, if possible. Referral, if needed. Stress management

Individuals
Large Groups:

3a. Demobilization & Staff Consult (rescuers);

3b. Group Info. Briefing for schools, businesses, and large civilian groups

Shift disengagement; or anytime post crisis Event driven. To inform, and consult.

To allow for psychological decompression.

Stress management.

Large groups.

Organizations

4. Defusing Post-crisis (within 12 hrs.) Usually symptom driven Symptom mitigation.

Possible closure. Triage.

Small groups.
5. Critical Incident Stress Debriefing (CISD) Post-crisis 1 to 10 days;

At 3-4 weeks for mass disasters

Usually symptom driven.

Can be event driven.

Facilitate psychological closure. Symptom mitigation. Triage. Small groups.
Systems:

6a. Family CISM;

6b. Organizational Consultation

Anytime. Either symptom driven or event driven. Foster support, communications. Symptom mitigation. Closure, if possible. Referral, if needed. Families.

Organizations.

7. Follow-Up; Referral Anytime Usually symptom driven. Assess mental status. Access higher level of care. Individual. Family.

Without going into details, you’ll notice that many of the timeframes are inconsistent with what we know about how trauma is processed and what we need to do to recover.  In fact, it appears that some of these interventions can interfere with normal processing – making things worse.

What people need is to know they’re supported.  What can happen is these CISM interventions can feel more intrusive than supportive.  (For more on supportive environments, see Servant Leadership, and The Fearless Organization.)

Research

It’s normal for me to review the research that underpins books.  Sometimes, I’m so intrigued by an author’s summary of an article that I must read it to get the details.  Normally, this process isn’t that complicated.  However, for this book, it was.  In some cases, like Pennebaker’s work mentioned above, the book said nearly opposite of what the study said.  In other cases, I found that the articles being referenced were retracted.  In still others, I couldn’t find the article at all.  While this can happen to even the best researchers, the breadth and volume of the challenges I found gave me reason to pause and wonder what was going on.

Trauma Informed

By the very nature of a crisis response, we must expect psychological trauma involvement.  It’s possible for someone to navigate a crisis without psychological trauma – or lasting trauma.  However, the principles of trauma-informed care apply whether the person is impacted by a trauma or not.  (See Restoring Sanctuary for trauma-informed care.)

CISM correctly identifies that sometimes telling a person in crisis what to do is the wrong thing – because they need to be given a sense of control.  Telling the person what to do is certainly appropriate if someone is at eminent risk that they don’t understand, and you need immediate reaction.  However, in most cases, the best response is to try to create choice and options.

Evidence

In the end, CISM has some “evidence” that indicates a positive response.  The problem is that the evidence is very weak “sentiment” type research rather than results research (which is admittedly hard).  It reminded me of the “smile sheets” that Kirkpatrick rails against in the education market.  (See How People Learn.)  On balance, I think people like CISM because it makes them feel better – but it’s not clear that it makes them better.  It’s still worth learning about Critical Incident Stress Management.