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Book Review-Reducing Secondary Traumatic Stress: Skills for Sustaining a Career in the Helping Professions

When you think about it, there are dozens of professions that are focused on improving society.  We think of first responders in terms of firefighters, law enforcement, emergency medical personnel, and 911 dispatchers.  However, we forget about our mental health professionals, teachers, child protective services, and dozens of other professions that are exposed to the traumas others are coping with.  Reducing Secondary Traumatic Stress: Skills for Sustaining a Career in the Helping Professions is designed to serve those who serve others by helping them learn to address the hardest parts of their jobs.


Early on, Miller speaks about burnout harking back to Freudenberger’s Burn-Out.  He incorrectly associates Maslach’s work with Freudenberger’s, perhaps because that’s the narrative that has been spun.  (I should say that Freudenberger’s book isn’t the oldest book on burnout: that distinction belongs to Professional Burn-Out.)

Miller, however, correctly identifies the key to burnout as feelings of inefficacy.  He challenges the notion that you’re burned out at the end of a long career and explains that burnout happens more frequently at the beginning of a career – not the end.  Of course, this is consistent with the research we did when building Extinguish Burnout.

Compassion Fatigue

Miller similarly pushes back against compassion fatigue.  He argues that it’s not that you’ve expressed too much compassion, but rather that you’ve closed yourself off to all feelings and empathy with the result of failing to express compassion for those you’re there to serve.  In Is It Compassion Fatigue or Burnout?, we speak about it from the perspective that professionals have failed to do their self-care.  The result is the same: you shut down, and it’s this shutdown that’s perceived as compassion fatigue.

Systemic Stress

Too many mental wellness programs are little more than herbal tea, soft lighting, and a once-a-month yoga session.  While these practices have some value, they’re often crushed by the onslaught of 50-minute sessions, crisis calls, and complex cases.  The physician that can’t find time for a bathroom break between 15-minute patient appointments won’t find what they need at the bottom of a teacup.  The paramedic whose sleep was just interrupted to respond to an accident doesn’t need soft lighting.

We can’t assume that we can put a band-aid on a gaping wound, and it will all be okay.  We have to match the care that we give to the need.

Feel or No Feel – There Is No Try

My apologies to Yoda.  You can’t selectively let in some feelings and dampen others.  You can’t decide to let joy through but block depression.  When we numb – either naturally or with pharmaceutical assistance – we block both the good and the bad.  This is part of Miller’s point: when we try to block out the struggles of empathy, we necessarily prevent the development of compassion.  We can either choose to open ourselves to experiences and live, or we can wall ourselves off from the world and from others.  If we choose that option, we disconnect ourselves from the broader community and their support for when we’re feeling low.

No Feeling is Final

What we know about feelings is that they change.  Even moods change over the longer course of time.  (See Emotion and Adaptation.)  It is hard to remember in the moment that the feeling will pass.  (See Capture.)  However, the only thing constant about feelings is that they do change.

There is something to be said for actively shaping your thoughts while accepting them.  One can work to hardwire happiness without preventing acceptance of other emotions.  (See Hardwiring Happiness.)  Too many people believe that feelings happen to you – and it can certainly feel that way.  However, we know that you can consciously influence your feelings by focusing attention on the emotions that you want to have.  Caution is appropriate here so that we don’t over emphasize what can be done, as Bright-sided and Happier? Are concerned about.

Removing Rumination

Rumination is the opposite.  It’s focusing on the same situation and the challenges associated with it without finding ways to resolve the problem.  Instead of problem solving, rumination catches us in a net of repetition.  (See Capture.)  If we want to break free from rumination, we must either seek to solve the problem, or we must learn to let go.

Miller proposes an ACES (Action, Concrete, Experiential, and Specific) model for problem solving.  You know it’s not rumination when you’re coming up with specific, concrete actions that are doable.  Problem solving doesn’t mean that you must solve the end problem yourself.  Even identifying the specific set of actions you’re going to do to ask for help is enough to allow your mind to let go of it.

It used to be that I’d be caught in a loop of trying to not forget something that I needed to do in the morning.  Now, I grab my phone, send myself a quick one-line email, and go back to sleep.  Knowing that I’ll see it in the morning allows me to let it go and move on to the important need for sleep.

Letting go of something is the other option.  It’s easier when you’re deferring it, but for some things that we ruminate on, we need to accept that we have no control of.  We can’t prevent something from happening or cause it to happen.  No amount of rumination will change the outcome.  As uncomfortable as it can be, sometimes we just must let the cards play out the way they’re going to play.

Energy Management

The narratives around burnout, compassion fatigue, and secondary traumatic stress are collectively focused on a false dichotomy.  They generally believe that your energy is drained or consumed at work and refilled at home.  The expectation is that work grinds you down, and your home life is fulfilling and life-giving.  However, for many people, this isn’t the case.

At work, they feel effective and fulfilled in their role.  They know what to do and how to get good results.  At home, they’re in a constant struggle with their spouse.  Their teenage kids don’t listen to them and are downright hostile.  They don’t know what they did wrong or what it will take to fix it – but they know they don’t like it.

More often, it’s in the middle, where some things at work build and renew a person – but there are times of exposure to trauma and tragedy.  At home, they find both love and challenge.  It’s not about the place but rather about the moment-to-moment environment that defines whether someone is receiving more energy than they’re giving.

Driving with the Brakes On

If you’ve ever had the experience of having a car brake caliper freeze up, you quickly have discovered what it’s like to drive with the brakes on.  (Hint: it doesn’t end well.)  A less eventful situation might be what happens when you forget and leave a parking brake on.  Unfortunately, that’s what happens with too many people.  Their sympathetic and parasympathetic systems get locked into a fight, and they get stuck or oscillate.  If we want better results, we’ll find a way to either have the brakes on or put our foot on the accelerator.

Generally, when the parasympathetic system (brakes) is engaged, the sympathetic system shuts down – but not always immediately.  With patience and practice, it becomes easier to downregulate and recover more quickly when we do become triggered.

Blessin’ or Lesson

Miller quotes a Southern saying that “everyone you meet is a blessin’ or a lesson.”  In other words, they’ll either attempt to bring you good or bad.  Either way, you must learn to work with them.  Knowing ahead of time which one they are is one step towards Reducing Secondary Trauma Stress.

Book Review-Trauma: The Invisible Epidemic: How Trauma Works and How We Can Heal from It

When Paul Conti’s brother, Jonathan, killed himself with the handgun that his father had been issued in the Korean War, his life changed.  It wasn’t simply that he experienced the loss of his brother, but it also caused his desire to focus on understanding trauma and why he couldn’t see the struggles his brother was facing.  In Trauma: The Invisible Epidemic: How Trauma Works and How We Can Heal From It, Conti tries to expose the internals of how we process trauma so that we can learn to see it and process it.

For Generations

One of the often overlooked aspects of trauma is that it has a ripple effect that expresses itself across generations.  In Why Zebras Don’t Get Ulcers, Robert Sapolsky shares not only the research from the adverse childhood experiences (ACEs) study but also the work on fetal onset of adult disease (FOAD).  To clarify, the stress of the mother can have a negative impact on the health of the fetus.  More broadly, we’ve begun to learn that it’s more than genetics that leads to health outcomes, it’s epigenetics.

That is, our genes are activated and deactivated by our environments.  While two identical twins start out with an identical set of genes and gene expression, through different experiences, they can end up with different gene expressions – and therefore different outcomes.

The implications of this are that a traumatic event or set of traumatic events can send ripples across time into future generations.

Marshmallows of the Future

In the person themselves, trauma changes things.  It makes the world a bit less stable.  It causes us to believe that our dreams and aspirations aren’t possible.  They’re not real.  Irrespective of the facts, we insist on staying in the here and now so that we aren’t disappointed when the future disappears.  This has a negative impact on our ability to hope.  (See The Psychology of Hope.)

When Walter Mischel tested preschoolers to see how they could handle delayed gratification, he didn’t realize what he was measuring.  (See The Marshmallow Test for a full explanation.)  Ultimately, the test was about whether children would sit with a sweet in front of them for a short time without eating it, with the promise of more if they did wait.  (It wasn’t always a marshmallow that Mischel used.)  Retrospectively, it seemed that those who could delay longer did better in life.  However, what’s more interesting are the strategies that the preschoolers used.  Some could clearly see the value despite the future, discounting what Daniel Kahneman explains in Thinking, Fast and Slow.  Other research, including Paul Tough’s in The Years that Matter Most, leads us to understand that those who have the most trauma have the hardest time trusting in future gains.

More tragically, trauma can leave us questioning our self-worth and our gifts.  We begin to consider life in terms of some sort of grand karma.  If we’re really good and worthy, then trauma wouldn’t happen to us.  Of course, that’s not fair, but it doesn’t stop the evaluation.  As The Halo Effect explains, life is probabilistic, not deterministic.  Bad things do, in fact, happen to good people.  While Thomas Gilovich explains in How We Know What Isn’t So that we have a bias towards believing better of ourselves than we should, trauma can reverse that wiring, so we believe we’re not as good as we are.

Presumed Control

If you speak with an abused child before they’re removed from the abusive situation, you’ll often hear that they believe the abuse they receive is their fault.  They believe that if they’re just a better child, their mommy or daddy won’t hurt them.  This illogical conclusion is the one that their minds are forced into, because the alternative is more painful and tragic than believing that they can, with their behavior, prevent the abuse.

If the abuse has nothing to do with how good or bad they are (or their behavior at all), then it’s unpredictable and unstoppable.  They must believe that the abuse and pain will continue forever – and that’s not something they’re prepared to do.

We all do this throughout our lives, not just in childhood.  We try to take control of the situation, so that we don’t have to fear it.  (See Compelled to Control for more.)

Inciting Illness

One way that we see this same dynamic in adults is when they believe that the trauma they experienced is their fault.  From the automobile accident that they blame themselves for to the cancer that couldn’t have been prevented, people believe that it’s their fault.  The result is shame – “I am bad” – driving the sense that they need to punish themselves.  Somehow in the punishment, they’ll equal out the scales of justice.  There are two key problems with this.  First, the sources of the traumas are almost universally external to the person.  Second, no amount of self-flagellation will even the scales.


Brene Brown calls it “enough.” (See I Thought It Was Just Me (But It Isn’t).)  It is the feeling that we’re not “good enough.”  We’re not “doing enough.”  We’re not worthy of what we have or even of being on the planet.  It’s the less extreme form of impostor syndrome that too many people routinely feel.  While inadequacy can be a powerful drive to cause people to strive to do more and be more, it comes at a cost.  The cost is both the happiness of the person and, sometimes, their life.  In Perfectionism, we learned the psychic toll that perfectionism – or inadequacy – brings.  When we believe we’re not enough, we can never get a break from ourselves.

The Costs of Survival

We celebrate the survivors of trauma of all kinds.  We admire their strength and their courage.  However, we never ask ourselves what it took to get there.  We celebrate the war hero who walked his team out of the firefight, and we don’t ask what he had to do.  We don’t want to know about the prisoner or little kid he had to kill to survive.  We don’t want to know how deep that trauma goes.  We fail to notice when we try to celebrate them, and they squirm away.  It’s more than being shy.  It’s a deep sense that if people knew what they had to do, they wouldn’t celebrate their return home in the same way.

Computers and Chainsaws

Both computers and chainsaws are tools with immense positive potential.  They’re also tools through which someone can inflict suffering.  With both, if we learn how to operate them safely, we can prevent trauma.  The unfortunate reality is that anonymous forums lead to mob-like or gang-like behavior where people become worse than they’d be on their own.  (See Going to Extremes and Delinquent Boys for more.)

Protecting people from unsafe spaces is, in part, requiring that individuals be held accountable for their comments – or, at the very least, having their name attached to them.

Not Mine

Whenever there’s a negative outcome, it’s appropriate to ask to what degree your behaviors influenced the outcome.  What could you have done differently?  What should you do next time?  These are healthy questions that can take an unhealthy turn we if decide that we need to not only own our own dysfunction in the situation but the dysfunction of others as well.  A wise friend once explained that “that’s not my shit.”  She explained that sometimes you’re not responsible for the negative outcome – or certainly not responsible for all of it.

It’s important to take responsibility for your part – but equally important that you not take responsibility that’s not yours.

Facts and Fallout

The law is concerned (ostensibly) with the facts.  They want to assign guilt and blame.  They are not equipped to help trauma victims cope with the fallout.  The penalties that are assigned to criminals are used as a deterrent to prevent their own and others perpetrating the crime in the future.  There as some crimes – like murder – for which there is no compensation.  Criminal trials aren’t concerned with that.  Civil trials are, but only a small fraction of trauma-inflicting events are the subject of a civil suit.

Criminal trials are themselves sometimes more trauma-inflicting than healing.  It can be hard to confront the person who injured you and hard to defend yourself against the questions and implications of their attorney.

Pre- and Post-Trauma

When people have a single, defining trauma, there seems to be a bright line between the before and the after.  The trauma created a change in the person (that may still be evolving).  That change can be seen in the pre- and post-worlds.  Sometimes, people speak of recovering or returning to the place before the trauma, but the place no longer exists.  We must build a new place with new awareness – and that isn’t always easy.

Given that it’s estimated that 90% of us will experience trauma in our lives, it makes Trauma: The Invisible Epidemic.

Book Review-Fighting Fires: How Emotional Trauma Sparks an Inferno

For many first responders, firefighters included, the idea of mental health is for the other guy.  It’s a tough job and you’ve got to “man up” and be tough.  However, at the same time, the things that first responders see, hear, do, and not do, are unforgettable.  They’re confronted with the worst that humanity has to offer.  It’s the most suffering, the most cruelty.  It’s also times of greatest compassion.  Fighting Fires: How Emotional Trauma Sparks an Inferno is David Lewis’ journey through trauma that he experienced outside of the job, inside the job, and through life.  No question he experienced trauma through his work as a firefighter, but that wasn’t the only trauma he experienced in his life.

Fire and Smoke

Lewis describes mental health as the pillar upon which life is built.  It’s a sound argument, since the life we experience is the one that we create.  Incognito shows us just how much of our lives and what we think is reality is made up.  Life is really what we make of it – and it can be filled with fire and smoke, or it can be fresh air.

Lewis uses the analogy that fire is the traumatic events that you see, hear, do, or experience.  Smoke is the problems as a result of that fire.  He properly places the focus on the fire portion, recognizing that smoke is a result of fire.

The Charlatans

Early on in Lewis’ attempts to get better, he describes running across an “internet guru” that claimed to have the elixir that Lewis needed to be “fixed.”  All it would take is a credit card.  The free materials seemed good, so Lewis parted with hard-earned money only to realize that the content behind the pay wall wasn’t really worth it.

The real problem is it’s easy to make things look like they’re good when it’s shallow; it’s hard to make sense of it when it’s deep and it matters.  I cannot count the number of burnout books that I’ve read where the authors had no breadth or depth in what they’re saying.  They saw the opportunity to make a buck selling some books and consulting, and they dropped right in.  (Even Maslach’s latest book, The Burnout Challenge, is woefully under-researched.)

Even professional mental health providers rarely read research or use evidence-based techniques.  Too frequently, they just do what they think works, leading to Science and Pseudoscience in Clinical Psychology and The Cult of Personality Testing.  Even in an area where the public is supposed to be protected through licensure, we’re confronted with the need to carefully screen people, as Lewis points out later in the book.

Coloring in unicorns may be fine for an eight year old, but it’s not appropriate for a professional firefighter – or most other adults, for that matter.

Buffalos and Cows

For the most part, cows and buffalo seem like similar animals.  They’re both mammals.  The buffalo burger is leaner but is similar in taste to a hamburger.  (Why “hamburgers” come from cows not pigs is a mystery.)  However, they have some different behaviors.  One is how they cope with the stress of a storm.  They react like people react.  Buffalo charge into the storm, while cows walk away from it – even when they’re in the midst of the storm.

The subtle change of moving into or away from the storm has a profound effect on how long the animal is in the storm.  The buffalo will spend much less time in the storm than the cow, because the storm passes over quicker.

As humans, we often turn away from our challenges expecting that we can escape them – but rarely is that effective.  Sometimes, the right answer is to face the storm and walk into it.


When the mental anguish becomes so strong that you’re fighting intrusive thoughts, there are many strategies that one may employ in an attempt to retain balance.  Unconsciously, there may develop a tendency towards obsessive compulsive disorder (OCD), including ritualized approaches to common activities.  We can deceive ourselves into believing that these activities protect ourselves and our families, when in reality they deprive us of the resources that we need to heal.

A more common and more socially acceptable approach is to become a workaholic.  (See The Globalization of Addiction for more.)  After all, being a workaholic means that you’re providing for your family.  However, the dark side is that work becomes all-encompassing, leaving little of the person for themselves or their families.  It’s common to believe that if you just work harder, you can block out the feelings and memories.  However, doing so deprives you of the very resources you need to live – and to recover from the pain and trauma.


As Compelled to Control clearly points out, we all love the illusion of control.  The illusion protects us in a random and ultimately unpredictable world.  It calms our consciousness as we confront the challenges of the world.  If we’re in control, then we don’t need to fear the world.  We can feel safe.

Some would say that we can control ourselves but not others.  However, in some ways, we’re so influenced by our environment, and we respond so instinctively at times, that it’s hard to convincingly say we’re even in complete control of our own reactions.  (See Thinking, Fast and Slow for more about how we lie to ourselves.)

Defined by Our Responses

It’s not the tragedies and struggles we’ve faced that define us.  What defines us is how we respond to them.  Problems, struggles, and challenges are the substance of life.  We can’t escape life without problems.  In fact, sometimes when we believe we’re helping animals, we’re dooming them, because they need the struggle.  (See Beyond the Wisdom of Walt for more.)

There’s no shame in being injured – if we can heal.  If we need help to be able to heal, then we should ask for it.

Worst Case Scenario

Sometimes, we’re so afraid of playing the worst-case scenario game that we won’t play it at all.  Other times, we won’t play the game fairly.  In a bit from a comedian friend, he speaks how his mother moves from how he isn’t overly responsible through owning dogs to having a child that dies of neglect.  This wholly illogical chain of thinking is the way that too many people think about worst-case scenario.

Instead of looking to the things that can happen and reasonably evaluating their probability and impact, we focus on the case where the Earth is impacted by an asteroid – something that’s both always a possibility and something that we have no ability to prevent or mitigate.

By avoiding the game, we trap ourselves into a set of beliefs about a threat or stressor that aren’t realistic.  Like a large shadow from a small person or animal, we magnify the size of the problem, because we refuse to look at it directly.

The Balance of Life

In a state of suicidal crisis, it’s possible to lose all sense of scale.  Lewis explains how buying a toy for his son and dying by suicide seemed to be of the same magnitude.  Somehow, he thought that the scales of justice would be even.  Reflecting on it, Lewis can see how “jacked up” his thinking was – but in the moment, the evaluation of the balance of life was such that it had no special meaning.

The research and reflections seem to validate Lewis’ experience that life and the possibility of hope aren’t given their due significance.

Focus Forward

Trauma, whether acute or chronic, is a tragedy.  It’s something that each of us must learn to process, to come to terms with.  We can’t run from our challenges, and we can’t pretend they don’t exist.  Eventually, they’ll add up to a point where they compel us to address them – and by that time, they’ve grown fearsome.  If we get the choice, we should want to pick smaller fires when we’re Fighting Fires.

Book Review-Trauma Therapy and Clinical Practice: Neuroscience, Gestalt, and the Body

A common experience in trauma is dissociation.  One of the clinical therapies most focused on grounding and being present – the opposite of dissociation – is Gestalt.  The intersection of these two opposites is an interesting space for healing.  Trauma Therapy and Clinical Practice: Neuroscience, Gestalt, and the Body walks in the middle of the experiences and shows how one might connect the two.

If you need a definition of psychological trauma, please see Trauma and Recovery.

Living in an Uncertain World

The heart of the problem with trauma is some event that shatters our beliefs about the world.  Psychological trauma is an event – something you’ve experienced or done – which cannot be integrated into your beliefs.  Too often, the belief that’s called into question is the one about the world being predictable.

Many people see the universe as a big clock with gears spinning and whirring.  Everything has the mechanical precision of cause and effect.  There’s no room for chaos theory or Lorenz’ tornado-causing butterfly.  (See Facilitating Organization Change.)  It is this predictable world that we live in, because it’s a place of safety.  If we believe the world is probabilistic, then we’ve got to accept that bad things can happen to good people, and that’s not okay.

Still, we know that probabilities exist.  We watch batters swing and miss at the baseball plate.  We play the lottery and expect to win – knowing that the probability is very small.  We spin the wheel and roll the dice but keep for ourselves a separate thought about the safety of our world.

The first thing to accept about our world is that it’s random and impermanent.

The Disconnect

Central to Gestalt is being in contact with oneself.  This is a conscious, and non-judgmental, assessment of the body and mind.  This includes feeling our breathing, our heartbeat, the state of our muscles, and so on.  It also includes an assessment of our emotions and whether they appear to be influencing bodily processes.

In some cases, trauma victims believe that exploring these sensations is dangerous, because it will bring back the traumatic event or that, once experienced fully, they’ll not be able to contain them.

Expanded Choices

A sign of trauma is constricted thinking.  Some things are, quite literally, unthinkable.  So, one sign that someone is recovering from – or healing from – traumas is the capacity to consider other options.  Capture explains how thoughts can sometimes enter downward spirals.  In Trauma Therapy and Clinical Practice, the statement is about the barriers to escaping those cycles.

The reality is that we always have choices.  Instead of the tightly coupled idea that someone or something “made you” do something, the more accurate statement is that you reacted to their action.  Emotion and Adaptation explains there’s a gap between stimulus and response, and that gap allows us to respond rather than react.  We can, in fact, choose our responses, if we decide we want to and we practice it.

Regulated Arousal

Much of the work on psychological trauma resolution is on increasing our capacity to process the event.  This can mean increasing our resources or decreasing the impact of the event.  Much of that is finding ways to regulate our arousal as we consider the event.  If we can reduce the emotional responses, including fear, to a more manageable level, we can better process the event.

On the surface, it sounds simple, but it requires a set of techniques like desensitization, building safety, and the core work of Gestalt, grounding.  These tools and others allow traumas to be processed and thereby stop their intrusive nature.  (See Trauma and Memory for more.)

Between Too Ordered and Too Disordered

Live is about making decisions.  It’s selecting the right choice or option for us at the current moment.  Much has been written about how we make decisions – and the consensus seems to be that there’s an optimal range for people to operate.  (See Decision Making and Sources of Power for more on how we make decisions.)

Gestalt views this from the lens of being too ordered – or too disordered.  You wouldn’t expect that even creativity is helped by some bounds, but that’s what Creative Confidence says about how to be creative.  So, despite getting a bad reputation, constraints can be helpful.  Simultaneously, they can be too restrictive and can choke off both creativity and joy.

Sometimes the traumatized person has added constraints to their world (by themselves).  It’s important for them to determine whether those constraints are too much – or if they need to add some healthy boundaries and limits.

Hovering at the Thresholds of Tolerance

Flow is a highly productive state that lives in the narrow band between challenge and capability.  (See Flow, Finding Flow, and The Rise of Superman for more.)  In this gap, research finds 5x performance gains and real growth.  It’s not hard to imagine how hovering around the edge of our tolerance might be a powerful way to learn to process trauma.  In fact, this is the core of desensitization: keeping people safe while moving them progressively closer to something that triggers them.

By hovering at the edge of tolerance, at the edge of safety and our capacity, we expand that capacity and make it more likely that we can process trauma at some point.  It’s critical here to celebrate the progress, because it can seem painfully slow when you want a solution now.

They Can’t Hurt Me, I’m Not There

Dissociation is a natural response to an overwhelming event.  When the event is very close to the threshold for processing, it may be that it’s only compartmentalized.  That is, we’re aware of it, and we can’t process it, but we’re still present and connected.  At the other end of the continuum, there’s severe, clinical dissociation.  Dissociation is a process of distancing ourselves from an event to protect ourselves from it and its impacts.

Obviously, if there’s physical trauma, dissociation doesn’t prevent that physical trauma from happening.  It does, however, separate the processing of physical trauma.  For instance, someone in an accident may see the scene from outside (and often above) their body.  They don’t feel the pain associated with physical trauma, because their consciousness is separate from their body.  It’s this dissociation that led more than one trauma victim to say, “They can’t hurt me, I’m not there.”

A technique recommended in the book when speaking with people who may be dissociating is to ask them what percent “in the room” they are.  It’s a continuum between wholly present and not present at all.  Often, the person you are speaking with – when prompted – can judge the degree to which they are currently dissociated, providing clues about whether it’s time to add more safety to the conversation or whether it’s safe to press on.

Relationships for Healing

Healing happens in relationships.  When you look at the factors that most impact outcomes in psychological care, the number one answer is called the “therapeutic alliance.”  (See The Heart and Soul of Change for more.)  It is the relationship between the therapist and the patient.  It’s much more important than the actual techniques in use.

In difficult work with substance use disorder (SUD) patients, Motivational Interviewing starts with engaging the patient, because without a relationship – even a professional relationship – nothing else matters.

While this book is focused on clinical applications, we know that we are most likely to influence the people with whom we have a relationship.  In fact, Everett Rogers in Diffusion of Innovations believes that it’s the only thing that can change someone’s attitude – and ultimately their behaviors.

Disorganized Attachments, Trauma, and Cults

Perhaps the most disturbing thought from Trauma Therapy and Clinical Practice is the way that trauma creates a disordered attachment style where none existed before.  Terror, Love, and Brainwashing explains that it’s disordered attachment that makes cults possible.  Often, the cult leader induces the trauma – but it’s also possible that a recent trauma could make people more susceptible to cult leaders, because they’re already partially or completely in a disordered attachment style.

I don’t believe you need to be a clinician to find ways to help people who have experienced trauma reconnect, and Trauma Therapy and Clinical Practice may have the tips to make that easier and faster.

A Week of Trauma Processing

If you’ve ever faced trauma in your life – of any kind – please share this to take a stand against continued suffering.

We never teach people how trauma affects us or what we can do to better process trauma.  It’s the stark realization after reviewing hundreds (if not thousands) of hours of training materials, books, articles, and webinars.  We know so much about how trauma – including secondary trauma – changes us, sticks to us, and harms us, but we don’t teach how to process it.  We don’t teach how to move to the other side of trauma, to release compartmentalization and move to processed trauma.

We’re so honored to change this.  We’re going to be teaching a workshop on how trauma impacts first responders and what they can do about it.  We’ll talk about how to avoid PTSD and how to move towards post-traumatic growth (PTG).  We’re going to share simple techniques that first responders can use for themselves and share with their peers.

To celebrate this work and to ensure that the resources that we’ll be providing in class are freely available, we’ll be posting a book review for a trauma book every day from November 27th through December 1st.  Be on the lookout for the tools that you can use to address the trauma that you’ve experienced.  Estimates place the number of people who will experience in their lifetime over 90% – effectively all of us will experience trauma.  We’re hoping that you’ll know what to expect and what to do when it happens – or learn it now so you can process trauma no matter how old it is.

Here’s the list of the trauma books that we’ve already reviewed along with those publishing this week.  (The links will automatically start working when they’re posted at 8AM EST each day.)

Book Review-Managing Suicidal Risk: A Collaborative Approach, 2e

The first highlight is “helping people find their way out of suicidal despair.”  That is a wonderful testimony and summary of Managing Suicidal Risk: A Collaborative Approach.  Sometimes when you read a book, you get a real sense for the heart of the author, and this is the heart of David Jobes: to reduce the pain and suffering that leads to suicidal despair.

(It’s important to note that this review is about the second edition of the book, and a third edition has recently been released with substantial revisions.)

Throughout this review, I’ll frequently simplify interactions as clinician and patient interactions, as Jobes targets a clinician audience for his book.  However, I strongly believe that the approaches and techniques that he teaches through the book are appropriate and applicable to anyone who is committed to helping others.  Suicide prevention is an odd space of behavioral health where there is no diagnosis.  There’s no need to diagnose someone with suicidal ideation, because they directly state it.  There’s no need to compare a set of symptoms against a syndrome listed in DSM-V.  Rather suicide risk is seen as a side effect or symptom of other listed disorders.  Caring individuals would want to steer clear of providing psychotherapy – but supportive human contact would be appropriate for everyone.

Carl Rogers

Though Jobes only refers to Carl Rogers a few times, there are echoes of his influence throughout.  I was introduced to Carl Rogers’ work through Motivational Interviewing.  Words like acceptance, worth, autonomy, empathy, and affirmation pervade Rogers’ work.  The hallmark that summarizes his perspective is “unconditional positive regard.”  This is in stark contrast to the traditional way that people who struggle with suicidal ideation are treated by clinicians.

To be fair, clinicians themselves are fearful.  As clinicians, they’re concerned for their license and their livelihood in the event that someone under their care dies by suicide.  Jobes addresses this concern later in the book.  More importantly, from a human perspective, they care.  You don’t go into a profession that requires so much work and exposes you to so much trauma if you don’t have a heart for helping others.  The fear of connecting with someone deeply and losing them is a fear that we all share as humans and one that too frequently creates a distance and difference.  These natural tendencies in service of the patients is one of the things that Rogers saw and called on his colleagues to fight against.

Sometimes, this shows up as simple courtesy of not interrupting; other times, it shows up as acceptance that the patient’s perspective is real and correct to them at the current moment.  Whether the clinician agrees or not isn’t the point, and directly disagreeing with a patient about their perspective won’t be helpful.  Jobes uses other words to describe the same sense of empowerment, support, and care and the need for clinicians to accept the limits of their control.


The truth is that if a patient wants to die by suicide, they can.  No clinician is going to stop them if they make the decision.  What the clinician – and human helper – needs to recognize is that no matter how well intended, trained, or skilled they are, it’s not their life.  We can support others through their difficult times and encourage other choices, but, ultimately, the choices are not ours to make.

Clinicians should seek agreement that suicide is an option for later – not now – without pushing for a “no suicide contract.”  The thought is that the clinician and patient are collaboratively looking for other alternatives and ways to change the patient’s life such that suicide no longer appears to be a viable option.  The agreement is not coercive but rather a statement of shared commitment that life should be the preferable option to death – if the important problems in life are resolved.

Understanding the Suicidal Struggle

Whether the person is a patient pursuing clinical treatment or they’re a someone who has disclosed their suicidal thoughts to another human, there is an inner conflict transpiring.  The person doesn’t want to die, but they don’t want to continue living the way that they’re living today.  Simply understanding the reasons why life seems unbearable is a good foundation for the work on perspective-taking and problem-solving that will lead someone away from the idea of suicide as an option.

Shneidman called it “psychache” – that psychic pain that pushes people towards the precipice of pursuing suicide.  (See The Suicidal Mind.)  The enlightened workers in substance use disorder (SUD) realize that SUD starts as the numbing of some psychic pain, and, progressively, the person becomes trapped by the behavior.  (See Chasing the Scream, The Globalization of Addiction, and Dreamland for more on SUD.)  While we focus on SUD from a drug addiction perspective, other addictions like eating, sex, and gambling share the same roots.  We’re avoiding a painful psychic reality.  These may – or may not – be less urgent and life threatening, though they’re more socially accepted.  Even more socially accepted is the idea of being a workaholic.  However, all of these expose an underlying pain that is trying to be suppressed – and that can only happen for so long.  Eventually, the object of numbing becomes ineffective or overpowering.

Techniques like Motivational Interviewing are effective at managing SUD.  It shares similarities in the suggestions of Jobes, and it’s based on Rogers’ work and perspectives.  It’s fundamentally a listening process that focuses on what is the most important to the patient – and it helps them address the circumstances (or, more often, perspectives) that are causing them pain.

Stress, Press, Overwhelmed, and Trauma

Conceptually, we all think we know what stress is – right up to the point where we’re asked to form a formal definition.  (Trust is the same way, as Robert Solomon and Fernando Flores explain in Building Trust.)  Stress is something inside – an evaluation, as Richard Lazarus explains in Emotion and Adaptation.  Stressors exist in the environment, but stress is evaluation of the potential impacts of that stressor.  (See also How Emotions Are Made.)  Stress is bad, as is thoroughly explored in Robert Sapolsky’s excellent book, Why Zebras Don’t Get Ulcers.

What Shneidman connected to stress was Henry Murray’s “press,” which is the stressor.  I struggle with Murray, because much of his professional work seems as much built on fancy as fact, as I explain in my reviews of The Cult of Personality Testing and Love’s Story Told.  However, that doesn’t remove the validity of the basic concept of “press.”  So, press – the stressor – is invariably connected to stress, but not without the mediating factor of internal assessment.  Unfortunately, we know from Superforecasting, Predictably Irrational, Noise, The Signal and the Noise, and other works that our perceptions are notoriously warped by seemingly innumerable biases.  Capture takes this further into a personal spiral that can lead us to despair.  It’s the personal equivalent of what Cass Sunstein describes in Going to Extremes.

In short, the precipitating factor, whether called a stressor or press, is mediated by our assessment, and that assessment is frequently distorted.

Trauma, psychological trauma, is often poorly understood as well.  Psychological trauma is simply being briefly overwhelmed.  (See Trauma and Recovery.)  Thus, being overwhelmed is trauma, and we frequently evaluate stressors in ways that are at least temporarily overwhelming.

Sidebar: Being overwhelmed can be more long-term and connected with burnout (see Extinguish Burnout) or can be of a shorter-term duration that is more of a traumatic event or moment.


The SSF-4, the Suicide Status Form, is at the heart of the Collaborative and Management of Suicidality (CAMS).  The form is eight pages long, with the first four pages being dedicated to assessment and treatment planning.  A second section helps to track risk through the process, and the final two pages track outcomes and disposition.

It’s important to note that integrated into the form is the core principle of collaboration.  In places, it encourages the patient to fill out the form.  In places, it’s explicitly collaborative.  In places, it’s also clinician-led.  This, along with strategic repositioning of the clinician during the process of completing the form, conveys a sense of partnership that’s often missing in clinical settings – and one of which Rogers would likely approve.

There’s a substantial amount of research and wisdom packed into the form as a framework for guiding interactions.  From a learning perspective, it’s a sidekick productivity aid.  (See Job Aids and Performance Support.)  Its consistent use allows clinicians to focus on their clinical treatment approach while being supported and guided in the CAMS framework.

The SSF-4 also serves another important purpose for clinicians.  It encourages the proper documentation that limits malpractice exposure.  People will be upset when their loved one is lost due to suicide, but the form encourages the documentation that appropriate care was given.

For non-clinicians, understanding the components can help shape the kinds of support that can be offered to others.  Jobes selected some of the most important indicators of risk for inclusion from a list of hundreds if not thousands of possibilities.

The Big Five Variables

The SSF-4 starts with asking the patient to evaluate their psychological pain, stress, agitation, hopelessness, and self-hate.  This is followed by an overall summary rating of risk.  Psychological pain is the psychache discussed above from Shneidman’s work.  Stress is, as we also saw above, a frequently misunderstood phenomenon; here, it’s combined with being overwhelmed.  The remaining three factors are addressed separately in the following sections.


A child blows air into a wand, forming a bubble of water and soap.  The bubble floats aimlessly along until a moment of weakness causes a single spot on the bubble to fail before the entire bubble collapses in an instant.  The failure isn’t subtle or slow. The child can themselves accelerate the collapse by disturbing the bubble, like poking it.  Agitation, which Shneidman calls “perturbation” after the word’s use in the physical sciences, doesn’t itself cause suicide, but it hastens the path towards it if a person is already so inclined.


To understand hopelessness, one must first recognize that hope itself isn’t an emotion but rather a cognitive process, as Rick Snyder explains in The Psychology of Hope.  He explains that it builds on both waypower – knowing how to do something – and willpower – the desire or energy to do it.  A dimension often missed in Snyder’s work is the possibility that these can come from outside the person through their relationships or society in general.  For instance, in Trust, Fukuyama explains that different cultures focus their trust on the individual, family, and society, and the greater degree that trust is focused externally, the greater the degree that hope has seeds outside one’s own capacity.

For willpower, we find that Roy Baumeister has a work with the same name.  In short, it’s an exhaustible and regenerative resource that can be strengthened like a muscle.  (See also Antifragile for more on strengthening.)  Baumeister’s work is also represented directly by Jobes in the concept of self-hate.


Understanding how people can become self-destructive rather than having self-esteem is a challenge.  Self-hate leads to self-destructive behaviors – which is obviously a concern for suicide.  In Delinquent Boys, Albert Cohen explores the need for status and the inevitable disappointment that sometimes leads people to a path of self-hate and delinquency.  Albert Bandura’s work on Moral Disengagement creates an opportunity to see how people can do reprehensible acts based on structure and how they might come to develop self-hate as a result of their acceptance that they have done bad things.

A stop nearer on the path to self-hate is shame.  Brené Brown has described herself as a shame researcher at times, and her library of authored works is extensive – see Daring Greatly, Rising Strong, The Gifts of Imperfection, Braving the Wilderness, and more.  The key to understanding the difference between guilt and shame is that guilt is about “I’ve done wrong” and shame is that “I am wrong.”  Left unchecked, shame can easily develop into self-hate.  If people with shame aren’t able to separate what they’ve done from who they are and accept their good attributes, they’ll land in a place of self-hatred – and therefore vulnerability to suicide.


Before continuing, it’s important to note that the antidote to shame and self-hate is acceptance.  As Richo explains in How to Be an Adult in Relationships, acceptance is critical for our relationships with others and ourselves.  No one is perfect.  We cannot expect to be successful if our goal is constant perfection.  In The Paradox of Choice, Schwartz explains how maximizers – those who have to have perfection – are less happy with their lives.

For those with high standards, the immediate pushback is that perfection is possible.  This is true in the short term but is necessarily incorrect across long periods of time.  The goal for anyone should be the best they can do – excellence.  Carol Dweck’s work on Mindset and Mihaly Csikszentmihalyi’s work on Flow make that clear.  We can grow, change, and be incredibly productive.  However, we cannot do that if we’re focused on blaming ourselves.

Another, more fundamental, perspective is to recognize that one of the key tenets of meditation and mindfulness is the acceptance of thoughts as they pass followed by a release.  Instead of judging our thoughts, we simply observe them.  We accept them as a natural and normal part of consciousness.  (See Altered Traits.)  The more we can accept that even good people do bad things, the more we can release self-hate.

Preoccupied with Others

One of the observations about suicidal people is that they can become overly concerned or even obsessed with others’ perceptions of them.  Reiss might describe this as someone who is high on status or acceptance (inclusion, in this context).  (See Who Am I? for more.)  Some are motivated by the perceptions of people around them and, as a result, are particularly sensitive to bullying and other forms of social discrimination.

There has been good and credible criticism of social media and the rise of both depression and anxiety.  (See Alone Together for more.)  However, so, too, has there been research showing that technology and our always-on, always-connected world can help people find connections with others that wouldn’t have been possible before.  So, while our technological world has the potential for harm, it has the capacity to help as well.

It’s important to note that it’s the preoccupation that’s the challenge.  The tendency to ignore other perspectives – whether external or internal – is problematic.

Preoccupied with Thoughts

Another type of person is “in their own world.”  They’re consumed by their own thoughts and perceptions.  While there’s a validation of some objective – if potentially cruel – facts with those preoccupied with what others think, there’s no objectivity when someone is preoccupied with their own thoughts.  There is no automatic mechanism that leads to an accurate and grounded sense of the world.  While focusing on oneself and improvement can allow for the kind of advances that are discussed in The Rise of Superman, so, too, does the disconnection from external signals represent a risk.  This is the sort of problem that Capture is concerned with.

Reasons for Living and Reasons for Dying

When you see suicide as the fight between reasons for living and reasons for dying – rather than a binary sense of a desire to die – one can see how there is a constant internal battle.  In Principles of Topological Psychology, Kurt Lewin explains force fields and the forces that move people from one state to another or tend to keep them in the current state.  Some research implies that the reasons for dying are more powerful than the reasons for living.  That may be the case.  It may also be the case that the reasons for living in suicidal people aren’t as strong as reasons for dying.

Research seems to indicate that suicidal people have less aspirational and inspirational reasons for living.  They’re less inclined to follow themes of hope, future, plans, and goals compared to those who are not suicidal.  In short, the reasons for living are hollow – and they’re also the same reasons people would give for dying.

Prohibition of Self-Harm

Thomas Joiner’s Myths About Suicide catalogs a set of myths.  The first one is that “Suicide is an easy escape, that cowards use.”  In Why People Die by Suicide, his interpersonal theory of suicide explains that people who die by suicide develop a capacity for self-harm.  They somehow override the biological imperative to live.  Managing Suicidal Risk shares, “The eye-blink response data show that multiple attempers were extremely reactive to the unpleasant images.”

We don’t know whether this is a result of causing them to recall their own attempt or if it’s just a particularly strong natural aversion to harm, including self-harm.  However, it is interesting how it may be that there may be some visceral, intrinsic, and immovable aversion to self-harm that keeps these multiple attempters alive.  To be clear, I feel sorrow that their lives are such that they’ve been forced to come against this barrier.


A hallmark of Buddhism is the need for detachment.  It’s not disengagement.  It’s still doing the best you can – but recognizing that you don’t control the outcomes.  (See The Happiness Hypothesis and Resilient for more.)  Therapists confronted with a suicidal patient feel the humanistic pull to save the other person’s life, but the problem is that they can’t.  They can influence – and should.  They can care – and they should.  However, it’s always the person’s decision to live or die.

One of the hardest things for new therapists to accept is that they can’t accept responsibility for the behaviors of their patients.  They’re there to support, but the choices are ultimately the other person’s to make.  If a therapist can’t detach, then their emotions will become entangled in the situation.  They’ll change their responses to defend their own feelings – whether or not that’s in the best interest of the patient.

Legitimate Pain

Consider this statement: “I have never talked to a suicidal person who did not have legitimate needs behind his or her suicidal words, thoughts, and behaviors.”  This direct quote leads us to the most important and appropriate path.  Rather than simply prohibiting the option of death by suicide, perhaps we should focus on understanding the factors in the person’s life that lead them to consider it – or want it.  We can remain focused on measures to prevent suicide, but shouldn’t we focus on the items that would remove the burdens, barriers, and pain that make them want suicide in the first place?  Instead of trapping them in a living hell, shouldn’t we fix the things that are, to them, making it a living hell?

John Milton said, “The mind is a universe and can make a heaven of hell, a hell of heaven.”  While it’s often not appropriate to change the objective circumstances that a patient (or friend) is in, it can be that we can help them change their perspective on things that are relatively neutral.  There’s a fine line here.  It’s not the idea of polishing a turd.  Instead, it’s about finding ways to accept the reality and make the best of it.  (Acceptance is another of Richo’s “Five As” in How to Be an Adult in Relationships.)

Managing Means

Whether it’s a firearm or a stash of medications, having means available to someone is not ideal.  We know that most people who have suicidal ideation and plans won’t change their means.  If they’ve already expressed “the” method that they’ve chosen, it’s appropriate to prioritize focus on (at least temporarily) reducing access to that method.  If it’s a firearm that’s the chosen method, finding strategies to reduce access, from locking it up to removing it from the home, are appropriate.  If medications can be safely locked up by other members of the home, that should be pursued.  It’s possible to leave a small quantity unlocked for legitimate needs and keep the larger quantities off limits.

Some methods are relatively impossible to restrict means for.  If someone decides to die by suffocation (hanging), there’s almost always something around that can accomplish that goal.  If they decide they’re going to crash their automobile into something, you can look for ways to limit access to their automobile, but if they need to live, this may be impractical.

In short, while means restriction is a good idea, it may not always be as practical as we’d like it to be.  Jobes makes the point that, as a clinician, it’s your decision whether to continue treating if they’re unwilling to restrict access to means – and he’s clear this is a tricky issue.

Observationally, I’d say that there will be some people who you won’t find a way to reduce their chosen means.  However, I believe there are strategies that can be employed that will signal you understand the reasons for not limiting means – like I feel I need my gun for protection – and simultaneously engage them in strategies that will have a protective effect.

Consider someone who says that they’ll die by firearm – but it will be a specific one, and they have multiple.  In this case, perhaps this firearm can be locked up in their home in a way that they don’t have immediate access – like having a friend change the combination and keep it, or keep the keys to a key-based lock.  They can keep another gun for protection, but the one they’d use for suicide isn’t available while everyone is working on keeping them alive.

Gun owners are very resistive to the guns leaving their homes in most cases.  Strategies that leave the guns in their home but locked in ways they must ask for access from another person can sometimes navigate this space.

Coping Ideas

The development of a coping idea list is a part of the recommended practice.  It’s simply a list of suggestions for things that someone can do when they feel particularly suicidal.  It can be simple, like take a walk or phone a friend.  Jobes makes the point that he’ll sometimes flip over his business card and write these ideas on it so that they have these ideas – and access to resources when these ideas aren’t enough.


Key in understanding suicide is that suicide is often episodic.  It’s something that comes and goes in waves.  Intense suicidal ideation may last an hour or less.  We need to make sure that we enable people with skills and resources that they can access during these times of intensity.  It’s important to understand and plan, but it’s equally important to encourage and enable people to be successful as partners in Managing Suicidal Risk.

Book Review-The Anatomy of Suicide

With an initial publication date of 1840, The Anatomy of Suicide is perhaps the oldest book I’ve ever reviewed.  A fair question would be what such an old text could teach us today.  The answer is both universal truths that haven’t changed in nearly two centuries and the things that have changed.  It’s good to know what was believed so we can see how we’ve made progress in our understanding and acceptance of suicide over time.


Since antiquity, there have been three “causes” for suicide:

  1. Avoiding pain or personal suffering
  2. Vindication of one’s honor
  3. To provide an example for others

The first is perhaps the most common and the heart of Shneidman’s psychache (see The Suicidal Mind).  In more recent times, less has been said about honor.  In America’s Generations, I summarized a progression of honor over time – and it’s not moving in a positive direction.  The idea of suicide as an example for others is definitely an extreme case of the protection against people taking advantage of others that is often exposed in the ultimatum game.  (See The Evolution of Cooperation and SuperCooperators.)

Justifiable Suicide?

While most people would agree with a general prohibition of suicide, many recognize that it’s not absolute.  In historical times, suicide was justifiable if one expected to fall into enemy hands and therefore to be tortured and murdered.  The water gets murkier when we speak of people who believed that they could no longer contribute to society or who were completely destitute and therefore decided to end their own life.

Today, in some countries, there is the concept – often well regulated – of suicide when a person is afflicted with a terminal illness.  So, while we share a general aversion to suicide, in some countries for some limited circumstances, we do accept that it should remain an option.

Compelled to Live

No one can be compelled to live.  Suicide: Inside and Out demonstrates how it’s impossible – even in an inpatient setting – to compel someone to live.  They must want to live.  You can reduce means.  You can try to remove every harm.  But in the end, you can’t prevent someone from suicide if they want to do it.

There’s a consensus that people who are suicidal learn what to say to inpatient doctors to allow them to get out.  (See How Not to Kill Yourself as one example.)  While the illusion of control is comforting (see Compelled to Control), it’s not reality.

Law and Consequences

No law can be made without the threat of some consequences.  The most dangerous situation is when the other person has nothing to lose.  Laws prohibiting suicide are problematic because the consequences must mean something to someone for whom not even life means something.  Threats of exposing the bodies to public display or some form of humiliation is one avenue that has been tried – with limited or no apparent success.  Being prevented from being buried on church grounds or even requiring burial at a crossroads has not made a measurable impact.  So, too, have penalties and forfeitures been levied upon the families of those who die by their own hand.  The result of these strategies has provided strong disincentive for coroners to accurately report suicides because of the repercussions.

Suicide is something that remains largely beyond the reach of the law.  Perhaps that’s just one reason why it’s not against the law in most parts of the world – the consequences don’t work.


What if you “knew” that nothing that you could possibly do would ever make up for the pain, hardship, and sorrow that you had caused others?  What if nothing that you could do could get you back to having at least a neutral impact on the world?  Being hopeless, self-loathing, or irredeemable would seem to lead to a sense that suicide is the right option.  After all, if you can’t make it better, you can at least exit the situation.

Of course, it’s not possible to say that you’re irredeemable, but in the throes of cognitive constriction and suicidal crisis, it may seem that way.  (See Capture for more.)  Rick Snyder in The Psychology of Hope explains that hope is a cognitive construct that relies both on waypower – or know-how – and willpower – the desire and drive to do.  Roy Baumeister explains in Willpower how willpower itself is an exhaustible resource.  In most cases, not knowing how to compensate for past harms (real and imagined) leads to an exhaustion of willpower.

How He Lives

It’s not how a man dies that matters, it’s how he lives.  It’s a simple cliché with a deeper meaning.  Often, suicide is evaluated as the final and ultimate act of a person’s life.  In doing so, it invalidates all the other good that they have done and minimizes them to a single moment.  Too often, suicide is the result of people believing that they’ve not lived well.  Whether that’s because of unrealistic expectations or the belief that living well means a life without struggle and loss doesn’t matter.  What matters is that those that choose suicide have judged themselves and their circumstances harshly.

False Medicine

Before ending, I should say that one must overlook the quasi-medical practices of the past that we’ve long since discovered did more harm than good.  There are references to bleeding people to let out the bad humors.  Similarly, there are references to disproven theories about phrenology.  It would be irresponsible to take medical advice from a text that is nearly two centuries old – but also irresponsible to discard the entire text because of some errors.  The truth is that every work has some errors.  Some are larger and some are smaller.  Our goal should be to take what’s valuable and leave the rest.

When Life Is Unbearable, Death Is Desirable, and Suicide Justifiable

Too often, the brief and momentary troubles are perceived as persistent, personal, and pervasive.  (See The Suicidal Mind).  Our goal in preventing suicide shouldn’t be the absolute prohibition or punishment of those who consider it.  Instead, we should endeavor to reduce suffering, to make life more bearable, and to make death undesirable.  Instead of removing the scales between reasons for living and reasons for death, we should find ways to pile on more reasons for living.

Maybe if we can look deeply at how people see themselves and how they’ve seen themselves over time, we’ll finally find a way to reduce suffering through a better understanding of The Anatomy of Suicide.

Book Review-Healing Developmental Trauma: How Early Trauma Affects Self-Regulation, Self-Image, and the Capacity for Relationship

What does it mean to have our development interrupted by trauma – and what do we do about it now?  These are the questions that Healing Developmental Trauma: How Early Trauma Affects Self-Regulation, Self-Image, and the Capacity for Relationship answers.

If you need a quick introduction to what trauma is before understanding what you can do about it, see The Body Keeps the Score or Transformed by Trauma.

NeuroAffective Relational Model (NARM)

The book is focused on a model called the NeuroAffective Relational Model (NARM).  The model is concerned with how our development may or may not lead to dysregulations, disruptions, and distortions.  These lead to difficulties in living our lives and ultimately reduce our ability to thrive.

The model suggests that we have five biologically-based core needs:

The model further suggests that if these needs aren’t met, they will need to be addressed, because they will create barriers to a fulfilling life.


Our bodies are amazing machines that allow us to achieve wide ranges of self-regulation.  From the mundane regulation of temperature, oxygen status, states of arousal, and the rest to the more complicated regulation of our emotions, we’re wired to achieve stability.  Of course, there are limits.  You can’t keep cool when you’re in intense heat.  However, overall, our systems are widely effective at the process of keeping us in states of homeostasis – relative balance.

When these systems are impaired, we experience it as a barrier.  Commonly, people who have been exposed to trauma have difficulty regulating emotions.  To be clear, as Jonathan Haidt explains in The Happiness Hypothesis, emotions are really in charge.  (See also Switch.)  Our ability to regulate our emotions is just an attempt to understand them and shape our responses.  Haidt’s model of a rational rider on an emotional elephant makes it clear that the elephant always wins when it wants to.

I prefer to position the work of regulating emotions as the perspective of the relationship between the elephant and the rider.  The degree to which our emotions are responsive to the requests and influence of reason can be harmed by early developmental trauma.  While Healing Developmental Trauma describes managing our emotions, I believe that this is too strong of a statement based on what we know about neurobiology.


NARM calls for mindfulness as a technique.  However, as they use it here, mindfulness is a catch-all term for a variety of approaches including more formal meditation techniques.  (See Altered Traits).  One of the specific approaches recommended is Somatic Experiencing (SE).  Somatic Experiencing is an approach developed by Peter Levine.  Healing Development Trauma and the NARM approach pulls key techniques from this work, including grounding, orienting, titration, pendulation, and discharge.  (See In an Unspoken Voice for more.)

Another component that is included in NARM is gestalt, which is a therapeutic approach developed by Fritz Perls, MD.  It’s focused on being aware of the current state – particularly, the current state of the body and what sensations are being felt.  This, too, is a part of the broader family of mindfulness.

Cognitive Distortions

“Cognitive Behavior Therapy (CBT) does not address the nervous system imbalances that drive cognitive distortions.”  It’s a problematic statement for me, because it’s not well supported in the rest of the text, and it’s not precisely true.  CBT does have some aspects of reality grounding in the overall suite of tools.  But the more challenging aspect of the statement is should it?  Cognitive distortions are just a separation of our perception from reality.  Some of these distortions are adaptive.  For instance, we know that depressed people have a more accurate – and negative – view of the world and their capability to impact it than non-depressed individuals.  Thus, non-depressed individuals see the world more positively than they should – but it’s adaptive.  (See How We Know What Isn’t So for more.)

Some cognitive distortions allow people to maximize their capacity for hope and self-agency.  (See The Psychology of Hope for more about hope.)  We shouldn’t limit those cognitive distortions.  We should be concerned about those distortions and those adaptations that are no longer working.

For Another Time

Each of us picks up a series of quirks about the way that we interact with the world.  They are adaptations and accommodations that we make either because a human in our life requires it from us or because the way that we see the world requires us to adjust.  We see this in the stereotypical differences between men and women in the way that they interact.  (See Radical Candor and No Ego for more.)

These adaptations and accommodations can be positive for the time that we adopt them.  It can be that they’re incredibly effective at helping us navigate the world.  However, over time, these may get progressively less effective or even become harmful.  They can begin to limit our growth as adults and our ability to navigate in the world of today.  That’s why we need to be aware of these adaptations and evaluate whether they’re still appropriate.


Sometimes those adaptations deprive children of their childhood.  Chaotic lives and parents who fail to plan sometimes find children creating the structure, organization, and planning that is necessary for the children to get what they need – like food and shelter.  (For some examples, see The Years That Matter Most.)  The problem this causes is that the child doesn’t feel safe allowing others to be themselves and often results in over controlling in their adult lives, because to not do so is too dangerous and scary.


Too frequently, we believe that if we share our entire selves with someone else, they’ll stop loving us – or they’ll leave us.  Too often, we hear about people who believe that others don’t know who they are and wouldn’t like them if they did.  (See How to Be Yourself for more.)  It’s one thing to do that with others – to deny a part of ourselves – but it’s a different thing when we do it to ourselves – hiding or limiting parts of who we are to become acceptable to others and to ourselves.

In No Bad Parts, we learned about the Internal Family Systems model, which explains that we have exiles (parts of ourselves that we deny) and protectors (parts of ourselves that are over expressed to protect us from harm).  In trauma, we find dissociation, which can cause the creation of the exiles and the protectors.

Degrees of Dissociation

In my reviews of The Body Keeps the Score and In an Unspoken Voice, I spoke of dissociation, but Healing Developmental Trauma identifies the gradations of dissociation.  Specifically, they use the analogy of a switch.  Some people dissociate with a dimmer switch, turning up their degree of numbing or muting their experience.  Others have a breaker switch, where they shut everything off completely and often experience the situation as if they’re outside their body.

So, the trick when working with people who have had trauma is to look not just for the complete dissociation but also the self-numbing that may be maladaptive.

Holding Framework

NARM proposes that “emotions are experienced and contained.”  I’d call it a holding space.  (See more in my review for Alone Together.)  A holding space is an environment that is capable of holding the emotion.  The goal is to create a space that is sufficiently safe, calming, and reassuring that the person is able to gradually experience the emotion without becoming overwhelmed.  You can see how I recommend this for small groups in my post, Small Group Safety Rules – Before, During, and After.

The key – as with Peter Levine’s approach in Somatic Experiencing – is to allow people to move into the experience and emotion to the degree that they’re capable of doing it and feeling safe.  (See In an Unspoken Voice for more.)

Unleash the Kraken

For some, the process of creating a holding space and offering a place for them to express their emotion is like asking them to unleash the kraken.  They fear that they’ll never be able to put their emotions back in a box.  They’ve been taught that emotions aren’t safe, and they’re not sure how to dance with experiencing emotions without being overwhelmed.  However, that’s what the holding space is for – to make it safe enough to experience the emotions and to learn that they don’t have to be overwhelming.

If you’re ready to help others – or yourself – work through your trauma and move forward with it in the past, start the process by reading Healing Developmental Trauma.

Book Review-How Not to Kill Yourself: A Portrait of the Suicidal Mind

“I believe for a vast majority of people, suicide is a bad choice.”  It’s not the first highlight in the book, but it’s close.  In How Not to Kill Yourself: A Portrait of the Suicidal Mind, Chancy Martin exposes his thinking after a lifetime of suicidal thoughts and attempts.  He shares the losses and poor choices that led to his extreme suicidal thoughts and his rationale.  This isn’t the first book I’ve read written from the perspective of a suicidal person attempting to illuminate the mental machinery of the chronically suicidal, but it is perhaps the most direct and raw.

The World as It Is, Not as I Would Have It

Most people stop the serenity prayer before its conclusion.  They recognize, “God give me the courage to change the things I can, the serenity to accept the things I can’t, and the wisdom to know the difference.”  It continues, “…taking the world as it is, not as I would have it.”  It’s a constant source of challenge for humans, whether addict or not.  We all want the world to be the way we want it – not the way that it is really.  It’s easier when the world conforms to our beliefs and expectations than when we need to shift our expectations and behaviors because of the world.

We’re eager to ascribe a reality on the world when it’s just our perception.  We assume that our friend overdosed rather than died by suicide.  We would prefer to believe that our friend got distracted rather than ghosting us.  It’s easier to take our predictions and believe they are reality.

The End of Unhappiness

It’s not a novel idea that people consider suicide to eliminate the pain in their lives.  Shneidman called it “psychache.”  (See The Suicidal Mind.)  However, the degree to which this desire to end unhappiness drives not just the suicide attempt but also suicidal thinking cannot be overstated.  When we’re in intense pain of any kind, our natural response is to end the pain.  Since emotional and physical pain are almost indistinguishable to the body, there’s no limit to the approaches we may try to eliminate the pain.

Survivors often ponder whether the person who has died by suicide thought of them or what the loss would mean to those who remained.  The short answer is no.  The longer answer is complicated.  In the long answer, they thought about those they’d leave behind, but it happens in a way that is not nearly as important as the need to end the pain.

Psychological pain is different.  It’s hard to quantify and hard to understand when others seem to have everything going well.  It’s hard to understand how the longings of their heart cannot be quieted or how they blame themselves for something they’ve done or the current state of their life.  These pains are often hidden from the view of others.

Emotional Pressure Vessels

For some people and some families, emotions aren’t safe.  Somewhere in their history, they’ve learned that emotions aren’t to be trusted.  If you expose anger to the light of day, it may lash out and harm others.  If you express fear, sorrow, or longing, you may infect others and the infection may consume them.  Like a Chinese finger trap, the inability to deal with emotions becomes a self-fulfilling prophecy.  There’s no opportunity to learn how to have healthy responses to emotions, because it’s not possible to experience or share them.  (See Descartes’ Error for more.)

Over time, we know that the pressure of not having emotions builds, and it can do severe damage to psyches and relationships when emotions finally force their way to the surface.  Invariably, when emotions are contained, they’ll find their way out.

In the world of suicide, we realize that unresolved, unexpressed, and unmanaged emotions can be the source of suicidal impulses.  Like the proverbial white bear that can’t be considered, so to do the things that we deny get bigger.  (See White Bears and Other Unwanted Thoughts for more.)


Many are quick to describe suicidal thoughts as irrational or the result of mental illness.  However, as Dan Ariely explains in Predictably Irrational, we’re all, well, predictably irrational.  This, however, isn’t always a bad thing.  Martin explains how he was afraid of a gun and not afraid of death.  It might be more accurate to say that he had a different fear relationship with death than most.  (See The Denial of Death and The Worm at the Core for more about the fear of death.)  No matter what his fear of death, he explains that he was afraid of his gun.  This seeming contradiction makes sense when you evaluate the fear of guns as a tool for violence separately from death.

Shifting the Hand of Fate

To this point, I’ve written as if Martin’s perspective was one of always wanting to die, always wanting to silence the voices of unhappiness, but that’s not fair.  Like everyone, Martin struggled with a desire to live and a desire to die.  It’s ambivalence, not knowing whether it is better to live or to die.  (See The Suicidal Mind for more on ambivalence in suicide.)  It’s quite possible, as Martin asserts from his own experience, that the person doesn’t know for sure whether they want to die or not.  It can be that there is no clear winner in the battle to live or die.

One way to bias towards death without overtly making a suicide attempt is to make risky decisions.  Risky choices can be thrill-seeking rather than a wish to die.  It’s more socially acceptable to die in an accident than to die by suicide.  (See The Rise of Superman for many deaths that were connected to risky behaviors.)

Consider for a moment an automobile accident where a car runs off the road and strikes a tree.  Was the person asleep at the wheel and drifted into the tree – or was the turn towards the tree intentional?  We cannot know.  Was it carelessness and risk-taking to drive while extremely sleep deprived?  Was this, as Menninger describes, “suicide by degrees?”  (See Clues to Suicide for more.)

One way to bypass internal prohibitions about suicide is to set up situations where death is a possibility rather than to directly make an attempt.  Who would be the wiser?

How to Speak with a Suicidal Person

Martin embeds clues to how to speak with a suicidal person.  He shares the widely held belief that you should be direct, specific, and fearless.  There’s absolutely something to be said for fearlessly asking whether someone is considering suicide.  There’s more to be said for the person who listens and hears yes but doesn’t run away.  It’s scary for everyone.  You don’t want to be responsible for someone else’s death, and even though you wouldn’t be, it doesn’t make the fear go away.

Martin is right that it’s the secrecy of the thoughts that provide the energy, and simply holding space for the thoughts can move towards resolving them.  What’s harder to see is that you shouldn’t directly try to contradict their perceptions that lead to the desire.  If they say that they feel unloved, you cannot tell them they’re wrong, you need to invite them to discover the cognitive constriction of their thinking.  (See Capture for more on cognitive constriction.)

The tools in Motivational Interviewing are particularly useful here.  Rather than trying to convince them they’re wrong, you can and should ask them for evidence supporting their conclusion – and for the evidence that contradicts their conclusions.  The process itself unwinds the thinking that leads to poor conclusions.

Heritage and Legacy

Martin shares some of this family history of mental illness and violence not as a way to justify his struggles but for further context.  These stories are startling because of their raw nature.  I’m not sure how I could respond to learning that my mother was the woman with whom my father was dancing at prom after he had tried to kill his own mother just hours before.

We all have a heritage we’ve inherited from our ancestors, for better and for worse.  The question is always what legacy we leave for others.  Perhaps Martin’s legacy is teaching people How Not to Kill Yourself when you want to.

Book Review-Terror, Love, and Brainwashing: Attachment in Cults and Totalitarian Systems

I don’t think about it as my cult experience.  I don’t process the interaction with Scientology as a near-miss with a cult.  However, Terror, Love, and Brainwashing: Attachment in Cults and Totalitarian Systems helps me to realize how close I really was.  (See my review of The Paradox of Choice for more on this interaction.)  I learned more about the recruiting methods, the progressive disconnect from reality, and the isolation that occurs as a part of a cult.

The Reason

It’s an appropriate question to wonder what prompted my interest.  The interest is tangential.  I recognize that cults must create environments where beliefs aren’t questioned.  In a cult, the leader’s word is the truth – whether it’s connected to reality or not.  The problem I’m trying to solve is how to get people to question their beliefs.  We live in a world of divisiveness.  (See Going to Extremes for more.)  We’re living in a world where people are no longer interested in social capital (see Bowling Alone and Our Kids).  People don’t want to work through and resolve issues with others.  (See Why Are We Yelling?)  Families are ripped apart because of disagreements and misunderstanding.  (See Fault Lines.)

The key question is how do we get people to question their beliefs?  Thomas Gilovich in How We Know What Isn’t So explains that people ask the question “can I believe?” when they agree and “must I believe?” when they disagree – and the second is a much higher standard.  How do we get people to question their beliefs?  Famously, the Wason Selection Task asks people to test how their beliefs might fail – and only 10% of people will do it.  (See The Black Swan, The Righteous Mind, and The ABCs of How We Learn for more.)

While Terror, Love, and Brainwashing doesn’t have an immediate answer, it provides more context and insight.

Built on Attachment

The system that drives the unwavering support of a leader is based on the psychological concept of attachment.  Bowlby first described attachment styles, and his work was later extended by others, including his student, Mary Ainsworth.  (See The Secret Lives of Adults, Words Can Change Your Brain, How People Learn, and The Satir Model for more about the work.)  Fundamental to the operating of the cult is not that people have a disordered attachment style to start but rather that the cult leader can induce a new attachment style.  Since attachment styles aren’t fixed and can be changed even in adults, it’s possible to take someone from a healthy attachment style to something disordered.

The disordered attachment style is one of conflict.  The person to whom a person is attached is both a source of comfort and connection as well as someone who induces fear.  This creates a tendency for both moving towards and away from them.  The result is a fundamental basis of fear and power that keep followers in an anxious and disoriented state making them susceptible to control.


Normal, healthy adults will naturally move away from a disordered state if presented with healthy models of attachment.  In fact, this restructuring of attachment styles is a part of twelve-step groups.  (See Why and How 12-Step Groups Work for more.)  Attendees at a twelve-step group are offered a community – other attachments – which can be used to reorder their attachment style.  This natural recovery process is intentionally subverted in cults.  As a result, the experience of being in a cult is one of loneliness rather than community.  (See Loneliness for more on loneliness.)

The isolation process from the outside world is rather obvious.  It means reducing – or eliminating – contact with families and friends who aren’t a part of the cult.  Internally, the mechanisms are a bit more challenging to explain.


In twelve-step groups, they say, “You’re only as sick as your secrets.”  In cults, the idea of secrecy is cultivated.  Just as a predatory human tells their prey not to tell anyone about their acts, groups make you suspicious of everyone and everything.  Arranged marriages reduce the bond of the marital union and pit one spouse against the other when it comes to challenging the word of the leader.  Both may struggle with something, but they fear talking about it because they’ll be turned in – by their spouse.

Alternate Relationships

A part of the exploitation can sometimes be termination of normal spousal relationships all together – or just that they’re controlled by the cult.  Certainly, I can accept that there are many approaches to sexuality that humanity has used over the course of history.  (See Anatomy of Love.)  However, the cult leader moves people into polygamy, promiscuity, and even pedophilia as a part of controlling the relationships in ways that prevent them from forming strong bonds.  By preventing strong bonds from forming, they can prevent the natural reorganization of attachment styles and simultaneously prevent alternate power bases from forming.

In the larger context of both internal and external relationships, it helps to believe that the leader controls them – and that you have no right to your own relationships because relationships are dangerous.

Fright Without Solution

One of the powerful motivators is creating a sense of fright without a solution.  When the group is locked in a virtuous struggle with the rest of the world, to lose means the destruction of the world as the followers understand it.  This creates a bonding force for the group and a fear that the world as they know it is in jeopardy.

We know from watching suicide rates that people become more involved and engaged in a group in times of crisis.  Consider how suicide rates went down after 9/11 or how rates decrease during world wars.  (See Assessment and Prediction of Suicide.)  If you want to drive group consistency, fear is a way to do it.

One might believe that the leader would be attached to these feelings of fear, but a righteous cause leads followers to believe that their fears are because of the outside world or even to events in their past that set them on the wrong road.

Voices in My Head

In a state of fear, the idea that the voices would become silent is a gift.  Much like those who die by suicide do so to silence their inner critic, those in cults treat the silence of their inner critic as tacit approval.  (See Stealing Fire for more on the inner critic, The Suicidal Mind for suicide as a method of silencing.)  However, the reason for the silence may not be approval at all but rather a complete shutdown of cognitive processing and decision making.  That’s okay, the followers are told, the cult will make their decisions for them.

Shutting down cognitive processing isn’t particularly easy – but it can be accomplished.  If you overload processing centers like the orbitofrontal cortex and prefrontal cortex, you’re left with someone who can’t tell right from wrong and doesn’t know how to process their intuitive sense for things.  (Bandura explains the processes in non-neurological terms in Moral Disengagement.)  Asch accomplished this in a test of line lengths.  By presenting people with confederates (actors) giving the wrong answer, he convinced people that two unequal lines were actually equal.  (See Unthink for more on Asch.)

Torrent of Misinformation

Today’s world is a torrent of misinformation.  It’s not just controversial leaders who are spewing misinformation.  Many of the “news” outlets report in a biased way that their journalism professors at universities would be appalled by.  Instead of reporting in a balanced way with research, the press, to hit a deadline, causes too many people – with and without journalism degrees – to take shortcuts.  The downstream impacts are a reduced trust in the news, people, and society.  However, this torrent of information – both internal and external to the group – gets us to information overload.  (See The Information Diet.)

Not only do we face this with people who are brainwashed as a part of their cult experience, but we also see this in the general population as we struggle to understand what is true and correct – and what is just noise.  (See also Noise.)

If you want to understand cults, maybe it’s time to get a better understanding of the Terror, Love, and Brainwashing.

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