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

Robert Bogue November 6, 2024 No Comments

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

Robert Bogue November 5, 2024 No Comments

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

Robert Bogue November 4, 2024 No Comments

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 180^th 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.

Prevent Suicide This Season

Robert Bogue November 1, 2024 No Comments

The cold weather of late autumn brings with it holidays and time to reconnect with loved ones. The holidays are a chance to spend time with those we’ve not seen in a while, whether it’s watching a football game or cuddled up under a warm blanket. When we connect with each other, we have an opportunity to bravely ask some hard questions.

Next week, I’ll be publishing a book review every day about suicide topics. These books discuss some reasons why people die by suicide and offer ideas on how to prevent suicide. One of these techniques is to directly ask if someone is considering suicide, because it won’t plant the idea in their head. As we spend time with our loved ones this year, we hope you can use some of these tools to better understand and connect with each other.

Book Review-Death and Bereavement

Robert Bogue October 22, 2024 No Comments

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-Critical Incident Stress Management, 2e

Robert Bogue October 14, 2024 No Comments

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.

Book Review-Transforming Trauma: The Path to Hope and Healing

Robert Bogue October 11, 2024 No Comments

Sometimes, you can agree with the goal and even some of the foundational premises of an author without accepting their extension into a place where there’s no empirical support. That’s where I am with Transforming Trauma: The Path to Hope and Healing. Much like The HeartMath Solution, there are extensions that simply don’t follow the evidence we have. Despite this, there are some good things about the book, what it shares, and how it can help It just leaves a lot to the reader to ensure that what they’re reading is supported by science – or at least not invalidated by it.

Meditation

I’m not going to take away the documented benefits of meditation. I wholeheartedly support and agree with them. (See Altered Traits and Happiness for two examples of solid foundations for meditation.) That being said, James Gordon’s assertion that “MEDITATION IS THE antidote to trauma” (capitalization original) is overstated. To understand why, we need to understand what the research does and does not say. James Pennebaker’s work shows the need to develop a narrative around trauma. (See Opening Up.) While meditation can activate the parasympathetic system and downregulate someone to a point of being able to address the trauma, it does not in and of itself neutralize the trauma. (See Emotional Intelligence and Reducing Secondary Traumatic Stress for more on the parasympathetic system.)

Gordon claims that “if you meditate regularly, the tone of your vagus nerve – its level of functioning – increases.” However, the referenced article doesn’t make such broad claims. Instead, it surveys mechanisms of meditation and references the relaxation and anti-inflammatory properties. This is a bit of tautology, because the vagus nerve is the parasympathetic system’s key driver – towards relaxation (or, shorthand, “rest and digest”). Similarly, anti-inflammatory is often a shortcut for saying a reduction in cortisol. (See Why Zebras Don’t Get Ulcers for more on stress, inflammation, and cortisol.) In short, there’s no support for the statement made – even if it’s generally a good thing.

Gordon also claims, “Much of the research on meditation has been done with people who meditate for forty minutes a day or more.” Here, the problem is that he’s isolated one measure – and not the one that’s arguably the most important. Much of the initial research was done with people who have extensive experience with meditation and showed dramatic effects. Altered Traits shares some of the more recent and much more transient work. Even short sessions over a few weeks can make an impact. So, there is research, and it’s the kind that’s important to people trying to recover right now.

Why is this important? It’s important, because we need to recognize that you don’t need to maintain meditation over the remainder of your life. There’s no singular prescription for a kind of meditation that’s necessary. The fact that you’re able to focus on something or nothing seems to be the key.

Fear of Emotions

Gordon correctly identifies that many people are afraid of their emotions. They fear that if they allow emotions, they’ll appear weak – or that the emotions will get the better of them, and they’ll be unable to control themselves. They feel as if they’re Bruce Banner who only needs to be provoked to become The Hulk. One of the ways that we can heal from trauma is accepting ourselves and, particularly, our emotions about the trauma.

Hypervigilance

A common compensation by those who’ve been traumatized is hypervigilance. That is, they can’t accept any threat ever impacting them again. They pursue strategies to avoid stressful or risky situations. They’re constantly on the lookout for the next potential problem.

Often, this leads to a need to control everything they can. The reasoning, even if unconscious, is that if it’s under control, then it’s not a threat. This can be the case – but it may not be.

Sadness and Fear

Gordon states, “Sadness and fear are similar.” Unfortunately, most respected scientists wouldn’t agree with him. Richard Lazarus explains how fear works in Emotion and Adaptation – and it’s not about sadness. While Lisa Feldman Barrett doesn’t agree with much that Paul Ekman says, neither believe that fear and sadness are similar in the way that Gordon states. (For Barrett, see How Emotions Are Made; for Ekman, see Telling Lies and Emotional Awareness.)

Triggers

Triggers are those things that lead people back to their trauma experience. Gordon states, “TRIGGERS ARE EVENTS – words, actions, or perceptions – that in some way resemble a past trauma and reawaken it.” The problem is that triggers don’t need to resemble the original event – they only need to remind people of the event. Even very odd connections work to drag people back to their trauma. Sometimes these connections aren’t (and can’t be made) conscious.

What’s important to realize is that triggers are a part of the amplification process. We see trauma get worse over time, because triggers cause their own traumas (by hyperactivation) that pile on to the original trauma and can exacerbate the problem.

The First Time Nobody Tried to Fix Me

It’s an odd thing. It’s what happens when you listen – just to listen. The person that you’re with feels different. They’re so used to people listening so they can respond that when someone listens with the full intent of simply understanding someone else, it’s special and different. One of the spontaneous things that happens is that people recognize “it’s the first time that nobody tried to fix me.” It’s the sort of thing that one would expect to hear when the other person has been trained in Motivational Interviewing. It could happen if someone experienced Dialectical Behavioral Therapy (DBT). (See Cognitive Behavioral Treatment of Borderline Personality Disorder.)

The Impact of Positive and Negative Responses

At some level, those responding to others who have experienced trauma believe that there’s nothing they can do to undo the trauma that happened. That’s true – but the important thing isn’t the trauma that has happened, it’s what is going to happen. Stories proliferate, like the one told in Transforming Trauma of a woman who was raped by her mentor and minister. The tragedy was that the way the system responded to her invalidated both her and the event – and led to forty years of needless suffering.

Trauma-informed responses can mean the difference between a hard period and a hard life. Obviously, we hope that every interaction is supportive and leads to less suffering – but that is tragically rare.

Keeping Pain from the Center

In the midst of a conversation about keeping gratitude journals, a conversation emerged about using gratitude journals as a technique for keeping pain from becoming the center of life. Gratitude journals, however, have some mixed evidence. Their use in acute cases, where people can’t understand what to be grateful for, is certainly warranted. (See Flourish, Hardwiring Happiness, Happiness, Positive Psychotherapy, and Happier?.)

However, I’m cautious about long-term use of gratitude journaling, because it becomes another task that people need to do – instead of providing positive effects.

Meaning and Purpose

Referring to Viktor Frankl, the book ends with a recommendation to find your meaning and purpose. (See Man’s Search for Meaning and also Simon Sinek’s Start with Why.) While it’s sound advice, there’s no guidance on how to do it. That can be frustrating as you recognize that you need to find your meaning but also are painfully aware that you don’t know how. Trauma sometimes closes people off from themselves, as is explained by the Internal Family Systems model in No Bad Parts. Sometimes, to find our meaning, we must first be freed from the weight of trauma, and it’s only then that we can achieve Transforming Trauma.

Book Review-Brainspotting: The Revolutionary New Therapy for Rapid and Effective Change

Robert Bogue October 10, 2024 No Comments

It started with a wobble and pause. Practicing a variant of EMDR, David Grand crossed the visual field of a patient, when her eyes wobbled, then locked – and Grand felt as if his hand was locked in the place where the patient was looking. Thus were the beginnings of what he calls Brainspotting: The Revolutionary New Therapy for Rapid and Effective Change. Conceptually Grand explains that, “Where you look affects how you feel.”

Roots

Before we can get to the heart of the Brainspotting approach, it is necessary to explain its roots. One of these roots is EMDR – eye-movement desensitization and reprocessing. EMDR is a validated therapy approach. The other component is Somatic Experiencing, Peter Levine’s approach, as explained in In an Unspoken Voice. While Somatic Experiencing has less empirical support, it’s generally regarded as promising.

EMDR is primarily focused on lateral eye movements, but other approaches, including hand tapping and audio stimulation, are used to trigger rapid coordination between the right and left hemispheres of the brain.

Somatic Experiencing is based on the concept that, during traumatic events, there’s energy released that our human brains thwart the release of. This happens when we suppress fighting or fleeing. When we freeze, Levine posits that we store that energy and fail to release it. He cites the reactions of animals as they recover from being frozen by a threat. Many, if not most, animals “shake it off” when they unfreeze, but humans don’t have this response. This is placed in the broader experience of recognizing and relating to our bodies (thus somatic). This is inclusive of acknowledging unpleasant sensations in the past or current.

From these two therapies, Grand created what he called “Natural Flow EMDR.” His previous book on this technique published 11 days before the tragic 9/11 attacks. As a result of the attacks, there was an influx of patients with trauma experience. (Grand is based in New York.)

Outside and Inside

The initial discovery required that the therapist observe a disturbance in the eyes of the patient. This is what Grand calls “outside window spotting.” That is, someone outside of the person is triggering and identifying the “brainspot.” The converse is when the person guides themselves and detects something as they sweep their eyes.

In both cases, there’s a catch. The catch is that the person must be “activated.” If they’re in a place of complete calm, they won’t be able to discover their brainspots. It’s a common thing for therapists and researchers to “prime” individuals so that they’re more receptive, so the idea that someone is activated isn’t particularly different or concerning. However, there is a careful balance to be struck. If someone is too activated, they’ll be unable to work through an issue – and if they’re not activated enough, the brainspots will likely not surface.

The Problems

There are a few problems with Brainspotting as a technique. First, the research on the technique is still very weak. The studies have low power, and the designs are subject to substantial therapist influence. It’s not been shown to be harmful – but the research is weak at best. This is normal for emerging approaches but with a 10 year history of Brainspotting, one would expect for more robust research support.

More than that, some of the assumptions that Grand makes are not well accepted either. For instance, while talking about blinking, he claims, “aspects of the brain are timeless, and so they experience this shutdown of visual input as a significant pause.” The research on flow indicates that time calculation in the brain is very complex, and it happens across multiple centers. (See Flow, Finding Flow, and The Rise of Superman.) We know that the ability to process time is quite frequently taken offline temporarily. Flow, in fact, is remarkable in the fact that changing blood flows in the brain takes the ability to maintain a sense of time offline.

Additionally, we know that the brain is constantly filling in details that are missing. Incognito powerfully shows what happens when your brain needs to fill in information, because one eye is covered and there is a hole in the remaining visual field where the retina attaches to the optic nerve. We also know that the rods and cones of the eyes have a slight retention of the previously recorded image – particularly when there is no new input. In short, the brain is in a constant mode of filling in information, so the milliseconds of time during the obscuring part of a blink aren’t significant in any particular way.

Holding Space

Like many therapies, Brainspotting proposes that we hold space for people. That is, we create feelings of safety – as much as is possible – and we accept them for who they are and for what has happened. This is an important aspect of healing that is often absent in our daily lives. It’s rare to hear people acknowledge their traumas, too – without trying to one-up the person sharing.

It can be that some of the moderate effects that are seen with Brainspotting are the effects of creating safety and validating the person for who they are.

Three Dimensional

A key divergence from the basis of EMDR is Grand’s discovery that the places where people could look and discover an issue are three dimensional. It’s more than the lateral movement prescribed in EMDR (x-axis). He introduced vertical (y-axis) movement as well with reportedly good results. Finally, Brainspotting has evolved to include a depth or z-axis dimension. There may be a trauma connection to this space, but it’s hard to say. It could be that exposing trauma can be done by concentrating on a point and can be resolved with cognition. If it is, then we should all start Brainspotting.

Book Review-The End of Trauma: How the New Science of Resilience Is Changing How We Think About PTSD

Robert Bogue October 9, 2024 No Comments

Trauma has a double meaning. It can mean the physical impact of an event – or it can mean the psychological impact. The End of Trauma: How the New Science of Resilience Is Changing How We Think About PTSD is focused on psychological trauma – but compares and contrasts it with how we heal physically.

Post-traumatic Stress Disorder (PTSD)

Before the DSM-III in 1980, the idea of psychological trauma had struggled to find acceptance. From the initial conditions, which were quite narrow (“outside the range of usual human experience and that would be markedly distressing to almost anyone”), to the broader acceptance of multiple kinds of trauma today, we have transformed our understanding. We know that everyone experiences events differently, and what may be trauma for one may not be trauma for another. More broadly, however, we recognize that, of those who experience trauma, not all of them – or even many of them – will experience PTSD.

Some are frustrated by the “disorder” part of PTSD. They’d prefer to call it a “syndrome” – a set of co-occurring symptoms. However, the distinction with disorder is that it has a negative impact on peoples’ lives – on their ability to function. Many who struggle with PTSD would freely acknowledge that it has an impact on their lives – and not a positive one. However, important to the conversation is the understanding that people can recover from PTSD – if not completely at least partially. Our goal should be to encourage the best outcomes, but that takes more than “just getting over it.”

Resilience

Crawford Stanley “Buzz” Holling first began using the word “resilience” to describe how forests and other ecological systems manage to endure. He explained that the instability in the system was what allowed it to stay alive. Unfortunately for Buzz, the word has been coopted by everyone who wants to sell a wellness course based on little (if any) research. Everyone wants to talk about how they make students “resilient” with an obvious lack of understanding of the word. (You’ll notice we avoid the word in our Extinguish Burnout work.)

The more contemporary definition of resilience is a return to the previous state. The problem here is that the way that things were will never be again. Heracles said that no man steps in the same river twice, for he’s not the same man, and it’s not the same river. In Antifragile, Nassim Taleb explains how we can use adversity to grow. Robert Sapolsky in Why Zebras Don’t Get Ulcers forms a similar conclusion but takes it further, arguing stress is necessary for our survival. Rich Tedeschi explains how growth is possible after trauma – and what seems to lead to it. (See Transformed by Trauma and Posttraumatic Growth.)

Our innate ability to recover from trauma is ordinary magic. It’s the thing that is both magical and expected.

Psychopathology

Just because you’re struggling with an event that was temporarily overwhelming to you doesn’t mean there’s anything inherently wrong with you. (One definition for psychological trauma is a temporarily overwhelming event.) Sometimes, people over-pathologize normal responses. In the absence of a serious loss, a sustained depressed mood might indicate a problem. After the loss of a spouse, a child, or close friend, a period of depression is the normative response.

It’s not wrong to experience and express strong emotions in the presence of a traumatic event. Some will argue that there are stages to traumatic response, perhaps aligned to those of Kubler-Ross’ On Death and Dying. Regardless of the model in use, they accept the reality of strong emotions not being pathological but rather being normal.

The Deception of Recovery

Because clinicians necessarily only see those patients who have struggled to process and resolve their trauma, encountering someone who has processed their trauma well is so outside of their experience that they may believe that the person isn’t “really” okay. This is a sampling error – or “what you see is all there is.” (See Thinking, Fast and Slow for more.) Like a black swan, just because it’s rare and you’ve not seen it doesn’t mean that it can’t happen. (See The Black Swan for more.)

Certainly, I’ve personally observed people who wanted to portray to the world that they’re better than they really are. I’ve also met people who were able to process and recover from traumas that others would have said weren’t recoverable from. The point is that you can’t easily tell whether someone is being deceptive about their recovery – or whether it’s real.

Impact

In terms of normative recovery, the scale of the problem is often inversely related to the difficulty in processing it. Natural disasters, generally, have some of the greatest impact to people and property – objectively speaking. Technical disasters, while tragic, tend to impact fewer people. Acts of intentional violence are even narrower still in their scope of objective impact. However, it’s the intentional acts of violence that cause people the most difficulty to accept.

Our belief in the goodness of others is shaken by the acts of intentional violence. We struggle, because we need to adjust our belief about the world. One thing that may make it better is Mister Rogers’ mother’s appeal to look for the helpers. (See Kindness and Wonder.)

Mindfulness and Resilience

There’s a lot of talk about mindfulness and how it leads to resilience. The problem is that there isn’t research to say that. There’s research to say that meditation matters – see Altered Traits, Happiness, and Emotional Awareness.) Dialectical behavior therapy (DBT) is a proven therapy for the treatment of suicidality in borderline personality patients. (See Cognitive Behavioral Treatment of Borderline Personality Disorder.) That’s why a recent study at Kaiser Permanente raised eyebrows when it said that DBT wasn’t effective.

It takes a closer look to understand why. First, DBT requires the balance between acceptance and the push for change. It’s the fundamental “dialectical” that Marsha Linehan was speaking of. Second, the study used only an online set of study materials for studying DBT, which, in my opinion, weren’t built with best practices for adult learning. (See Efficiency in Learning for more.) Third, and importantly, of the 24 skills of DBT, only four skills were selected for training – all of which were mindfulness.

For me, it had no chance of being successful, because it failed to adhere to the spirit of DBT – but it also attempted to teach the part of DBT that isn’t individually supported by research.

Behavior and Personality Traits

The degree of agreement between behavior and personality traits won’t be a surprise to anyone who has seen Kurt Lewin’s work and his formula that behavior is a function of both person and environment. (See A Dynamic Theory of Personality.) Nor will it surprise anyone who has read Steven Reiss’ work about motivators in conflict. (See Who Am I? and The Normal Personality.)

However, it tends to surprise people who believe in personality tests like CliftonStrengths (see Strengths Finder 2.0), the Enneagram (see Personality Types), or the Myers-Briggs Type Indicator (MBTI – see Quiet.) In fact, entire books have been written about The Cult of Personality Testing.

Emotional Suppression and Reprocessing

Suppressing the emotion related to a trauma is a bad plan. (See No Easy Answers, Assessment and Prediction of Suicide, and How Not to Kill Yourself.) However, there’s not a ton of solid long-term research that proves that repression of emotions is bad as compared to expressing them – due in part to the difficulty of doing that kind of research.

However, there is research that says that if you have an option to change the situation or simply change how you feel about a negative situation, changing the situation is better. While reprocessing events is almost always a positive experience, solving the real, tangible, underlying problem is more effective. Said differently, it’s better to feed someone rather than help them to feel less hunger pain.

Flexibility and Environmentally Appropriate Skills

Flexibility is our ability to adapt to our environment and use skills that are tailored to the situation. Using environmentally appropriate skills is the best strategy, because no one skill or set of skills is best in every situation. Developing this flexibility is two components. First is learning a set of skills and when they’re most likely to be useful. Second is learning how to understand the environment so the most environmentally appropriate skill can be used.

Maybe by using the right skills at the right time, we can find The End of Trauma.

Book Review-What Happened to You?: Conversations on Trauma, Resilience, and Healing

Robert Bogue October 8, 2024 No Comments

It’s easy to assume that people who are famous and wealthy have had it good their entire lives, including now. It’s harder to realize some of the awful tragedies that were wrought in their childhoods. It’s harder to consider that they’re still humans who grew up with trauma that left scars. What Happened to You?: Conversations on Trauma, Resilience, and Healing is a collection of writings and interactions between Oprah Winfrey and Bruce Perry. It’s about increasing the understanding about the trauma that others have encountered to be able to understand their curious behaviors.

Oprah Winfrey

Born in Kosciusko, Mississippi, Oprah Winfrey has come a long way from the child of a one-time hookup between her mother and father. She spent much of her formative years with her grandmother until her death, when she alternated between her mother and father. From this unstable upbringing, she recalls the pervasive feeling of loneliness.

Though not addressed directly in the book, Oprah has spoken repeatedly about the sexual abuse and rape she experienced growing up and has worked tirelessly to prevent the harm to other children. In addition to her personal experience with trauma, Oprah covered the issue of sexual abuse 217 times on her show.

Learning to Love

Children’s brains don’t create linear narrative memory before the age of about three, when the brain prunes connections and develops this capacity. In theories about trauma, it’s believed that traumas encountered before this time can’t be recalled but are still somehow encoded in the child. Conversely, it’s believed that supportive environments change the way that people experience the world.

Much has been made of attachment styles and the way that they change how people respond to different situations, including the “strange situation” test developed by Mary Ainsworth to test the theories of her mentor, John Bowlby. (See Attached.) There’s strong research indicating that children develop a greater ability to explore the world when they routinely encounter others that respond to their needs. Those who encounter neglect or negative outcomes when they share their needs are classified with insecure attachment styles, which hold them back in their relationships for life.

The good news is that attachment styles, while initially set as an infant, are malleable. If children encounter supportive, responsive relationships later in their life, their attachment style can shift towards more security and better outcomes. (See Attachment in Adulthood.)

In essence, when children encounter love, they learn to love. That love should come from parents but doesn’t always.

Repeating Patterns

One of the recurring tragedies of trauma is that, often, the person who was traumatized as a child replicates the pattern of abuse and trauma as an adult. Because a child can’t see the difference between their experience and healthy or normal, they unwittingly replicate it. Unconsciously, they may be trying to find a better outcome, like the son who became a doctor. It wasn’t until much later that he would realize his mother was always kind to the doctor in ways she wasn’t kind to him. He wondered if, unconsciously, he had chosen to become a doctor with the idea that he could finally get his mother to be nice to him.

Others aren’t so lucky in the way that they try to replicate what they experienced as children. Women find mates who are controlling and abusive instead of supporting and caring. Perhaps, at some level, they hope they can change their mates when they couldn’t change their situation as a child.

Reality is the Problem

Oprah recounts an interaction with Russell Brand, who wrote Recovery, when he said, “Reality is my problem, drugs and alcohol are my solution.” If you’ve been abused or neglected as a child, your perspective of reality might be that it’s a painful place with nothing for you. Instead, it’s a place where you can expect only to be hurt. In these cases, like Brand’s, it makes sense that reality is a problem. If you’re not hurting now, the perception is that you could be hurting at any moment.

There is a stigma about substance use disorder (SUD). It’s believed that people who become addicted are bad. Someone did something wrong. However, as Dreamland, The Globalization of Addiction, and Chasing the Scream all explain, it’s not that. It’s that they found life unlivable and sought an escape. As Judith Harris Rich explains in No Two Alike and The Nurture Assumption, you can’t protect your children from everything. They may experience hurts that you can’t protect them from.

Robert Putnam, in Our Kids, explains that some neighborhoods have better protections. Some don’t support their children in ways that lead them to the greatest success. It’s not about the kids. It’s that the odds are better sometimes – and that there are no guarantees even with the best parents or in the best neighborhoods.

Stressing Growth

If too much stress is trauma and it’s not good for you, then one might think that no stress is the goal. However, Nassim Taleb makes the point in Antifragile that we need stress. Anders Ericsson makes the same point in Peak as he speaks about professionals at the peak if their profession. Quiet Leadership speaks more generally about the need to have struggles for our growth. While the idea of a stress-free life sounds good, a complete lack of stress leads to apathy, and that’s not good.

Event, Experience, and Effects

Trauma is defined by three Es: event, experience, and effects. The event itself is easy to identify. It’s the thing that happened from an objective point of view.

Experience is a bit different than the objective experience. It includes how you initially assessed the event, including how it’s related to previous experiences, as well as what it felt like. Effects are the down-stream impacts of the event. If you’re in a car accident, there may be surgeries, physical therapy, or even permanent changes to your state of being.

Each of these plays a part in the impact of an event and whether it will be overwhelming and thus a trauma. (See Trauma and Recovery.)

The ACE You Can’t Keep

It’s hard to not have heard about the adverse childhood experiences (ACEs) study. The spooky results showed that there were lifelong effects to having experienced more traumatic events in childhood. The more events, the worse your adult health. Why Zebras Don’t Get Ulcers discusses it, as does Trauma: The Invisible Epidemic and It’s Not You, It’s What Happened to You. Even How Children Succeed spoke of how ACEs impact children’s success (beyond health measures).

As a population health tool, the ACEs survey is useful. As a clinical tool or to predict individual outcomes it’s not that useful. It suffers from many of the same problems that Craig Bryan explains in Rethinking Suicide. You just can’t make the statistics work like that.

Finding Flow

Perry explains that “flow” and being “in the zone” are partial dissociative states – that is, you start to disconnect from the reality around you. The concept of flow was developed by Mihaly Csikszentmihalyi and is the subject of his books, Flow and Finding Flow. Many have spoken about the power of flow, including Steven Kotler in The Rise of Superman. Flow, in addition to its dissociative aspects, is a highly productive state and, that may be why Perry explains that people who can control when they go into flow have a gift.

I struggle with Perry’s focus on unescapable distress and pain as a trigger for flow, because it feels as if he’s speaking of dissociation but not the same state that Csikszentmihalyi is speaking of. Csikszentmihalyi speaks of flow as a delicate balance between skills and challenge – a situation that isn’t present in the traumatic situations Perry is describing.

Loss of Innocence

I was doing a publisher-sponsored review of a book to provide feedback to the author about what could be improved upon. One of the big flags for me was the continued use of the phrase and concept of “loss of innocence.” The point I made is that only our first trauma deprives us of innocence. The second through the thousandth still impacts us without necessarily displacing innocence. After trauma, we’re different – but not just in the loss of innocence.

One of the words that I struggle with is “resilience” At a literal level, it means a return to a prior state. The thing is that, with humans, every trauma changes us. Heracles said, “No man enters the same river twice. He’s not the same man and it’s not the same river.” It is the same with trauma. Even when you’ve processed and recovered from the trauma, you’re still not the same.

Knowing

Oprah, as an adult, encountered a time when her mother was dying. It was then that she wondered if the millions of television viewers knew her better than her own mother did. The past loneliness that was endemic in her childhood hadn’t fully left her. Instead, she still wondered if, even at the end of her life, her mother really knew her.

As people share their experiences today, for better or worse, we should continue to wonder What Happened to You?

Public Speaking