Book Review-Suicide and Mass Suicide

Robert Bogue September 5, 2025 No Comments

It was the 1960s when Suicide and Mass Suicide was published, years before Jim Jones. It was a time when people were even more hesitant to discuss suicide than they are today. It was a time before research identified that some beliefs we held about suicide are really myths. (See https://SuicideMyths.org.) Yet some truths persist to this day that we seem to have forgotten – or, at least, we no longer realize.

The Deluge of Advertising

Even in the 1960s it had become apparent that the Western world, particularly America, was under a deluge of advertising. It fueled consumerism and the wheels of capitalism and, more importantly, drove a sense of deprivation and dissatisfaction. (See The Anxious Generation.) Little did they know how bad it would get, leading to an epidemic of Loneliness. We’d see an explosion of product offerings. (See The Organized Mind.) We’d develop technologies that would lead us to feeling more connected and less connected simultaneously. (See Alone Together.)

They Owe Me

Today, people are concerned about the entitlement of young adults. They claim something about how “their generation” believe the world owes them something. The problem with this statement is that every generation seems to have felt that way about the generations that came behind them. (See America’s Generations for more.) There’s a real reporting in this book – published in the 1960s – about the very kind of entitlement that we speak of today.

This feeling of entitlement, which seems more consistent across generations than variable, creates a problem that sometimes leads to suicide. It is the friction between the way the world really is and the way that people see it. If you expect the world to bend for you – that it owes you something – then you’ll be disappointed, confused, or dejected when it doesn’t work out your way. This state sometimes ends in a suicidal death.

Give me Success or Give me Death

Patrick Henry’s impassioned plea, “Give me liberty or give me death!” swung the argument towards revolution. However, the idea that if someone isn’t successful – in the thing that they want – then they should die isn’t remotely the same thing. It may not be entitlement, but it definitely has more than a hint of narcissism. “If the world refuses to bend to my desires, then I shouldn’t be in it,” is the very real message being conveyed.

It’s the mismatch between unyielding expectations and the harsh reality of life that too often causes a collapse into a suicidal state.

I’d Rather Die than Change

Another related pattern of thinking is a sense of righteousness. That is, people believe their way – and what they’re currently doing – is right. In fact, it’s so right that everything else must be wrong. Being wrong on this point is so critical that the only response is to die.

The core ideas have become so fused with their identity that death of the ideas would be a form of psychological death. Strangely, that’s worse than their corporeal death – at least in their minds.

Ambivalence

There is something to being human that seems to require contradictions. Most of the time, ambivalence is just a bit of friction, as one part of our thinking rubs another. It results in others not being able to predict our behavior. It results in our own awareness of our erratic responses and preferences.

However, when suicide is involved, we’re sitting on a dangerous see-saw, where one side of us wants to live and the other wants to die. If we’re under the power of the side of us that wants to die – even for a moment if a method of suicide is present – we may find ourselves on the wrong side of a statistic.

In these cases, we have two goals, neither of which will be perfect. The first goal is to minimize the times when the desire for death is winning. The second goal is to reduce those times when we have a method of suicide available. Much has been made of the difference in outcomes by simply inserting small delays between the impulse (desire to die) and the ability to use a method to die by suicide.

It’s important that I note here that some people are chronically suicidal, and inserting time between them and their method may not be useful, such as in those that choose to die on the Golden Gate Bridge. (See Half in Love with Death for chronic suicidality.)

Passive Surrender to Fate

Much has been written about the atrocities of the Nazi concentration camps where millions of Jews were mercilessly executed. Viktor Frankl in Man’s Search for Meaning describes a kind of suicide that we rarely consider. That is a passive surrender to fate. He describes what kept him alive in the concentration camp. He also describes the kind of passive surrender to fate that can’t be distinguished from suicide in practical terms. Anna Freud called this “Identification with the Enemy,” a distasteful way of describing how people lost their will to live and then lost their lives.

Mourn the Dead

Another great tragedy of the concentration camps was that those who survived would too often go on to die by suicide. The studies of the survivors found that the greatest complaint of those who did survive is that they weren’t allowed to mourn those they had lost in the camps. The sheer volume of death and the horror of the system of management made it impossible for anyone to mourn those who died, and the lack of a cathartic ceremony was felt years later. (See The Rites of Passage for more on the importance of ritual, and Disenfranchised Grief for the impact of being unable to grieve.)

Whether this lack of closure was directly related to the suicides is impossible to know – but it’s clear that we need ways of gaining closure, and they didn’t have that opportunity.

Suicide Among the Jailers

Much less has been written about the psychological torment of the jailers. Albert Bandura wrote Moral Disengagement, which explains how the jailers could do horrible things without overriding their morals. The Lucifer Effect focuses on other jailers and their responses.

What has been missed are the suicidal deaths of the jailers, which was apparently a consistent problem. Apparently, for some, the Nazi approaches for breaking apart moral safeguards didn’t work. The only solution available to the jailers – they believed – was to kill themselves. At least they wouldn’t be a part of the evil machine of the concentration camp any longer.

Hari-Kari

In some cultures and in some circumstances, suicide has been sanctioned by the culture. In Japan, to commit seppuku is to die by ritualized suicide with an abdominal cut. In Inuit cultures, elders often walk off from the group when they sense that there are scarce resources and that they’re a drain on the community.

We like to believe that suicide hasn’t been socially sanctioned, but reality is far from this belief.

Feeling Alive

In The Rise of Superman, Steven Kotler says that we misunderstand adrenaline junkies. He claims that they’re flow junkies instead. Whatever you call them, it’s clear that some people need pain or anxiety to feel alive. For some, the mundane reality of everyday life doesn’t provide sufficient stimulation to feel alive.

More Afraid of Life Than Death

Jerry Seinfeld has an old routine. He explains research that highlights various fears, including public speaking and death. The punch line is that people are more afraid of delivering a eulogy than being in the casket. While Seinfeld’s comment is a joke, the point where you’re more afraid of living than being afraid of death is a dangerous and confusing place to be. (See The Denial of Death and The Worm at the Core for more on our fear of death.)

It’s confusing when thinking about what’s the worst that could happen. Shouldn’t the worst that could happen be death? The answer is no. The worst possible outcome is to live in constant pain. This may be why even people who jump through the hoops of suicide laws rarely use the option even when they’ve earned it. (See Rational Suicide, Irrational Laws and November of the Soul.)

Protection from Oneself

From my perspective, one of the most challenging aspects of suicide prevention is learning how to navigate the line between individual autonomy and societal responsibility. How much should we allow people to make decisions about their life and death? How much should society ensure that people are protected – even from themselves? These questions are at the heart of Suicide and Mass Suicide.

Book Review-The Suicidal Child

Robert Bogue September 4, 2025 No Comments

It’s unthinkable to most people. How can there be The Suicidal Child? How is it that children can believe that death is the answer when they don’t even understand death? How do we navigate the space where we know decision making isn’t fully developed? These are the questions that The Suicidal Child sets out to answer.

Where Understanding Death Starts

We’ll need to grapple with the question of whether someone can be intent on suicide if they may or may not understand death, but how big a problem is it? Some studies point towards suicidal behavior in children as young as 2½ years old. Others insist that children don’t fully understand the finality of death until 10 years old. Other work points to the behaviors of preadolescents that have clear self-harm intentions.

The short answer is that, as of 1986, there aren’t clear answers. As it turns out, I’m not sure that four more decades of research has really settled the question. The only thing that we do know is that people underreport suicide in children and adolescents.

Death without Understanding

No matter what assumption we make about when understanding starts, and knowing that we should definitely consider a behavior a suicide attempt, we still have the gray areas where the behaviors are clearly for self-harm even when death isn’t fully understood. While it may feel like an academic exercise, it has important implications, because much of the work on suicide is founded on the concept that the person understands death.

In the end, The Suicidal Child argues that any concept of death – no matter how idiosyncratic – counts. That effectively moves the capacity for suicide attempts to when children have the motor control to attempt to achieve their objectives.

Detection

Overall, our ability to detect suicidal intent through warning signs, screening, and assessment is very poor. (See Myth: Every Suicide Attempt Has Warning Signs for warning signs.) It should be no surprise, then, that our capacity to detect suicidality in children isn’t good.

We won’t ask the questions or start the conversations about suicide with an adult. We’re less inclined to do it for children, who many people believe can’t have these kinds of thoughts. Because it’s inconceivable, we don’t ask about it and are rarely concerned about it.

Pressure Cooker

Even back in 1986, there was a peak in suicide death in the range of 15-24 year olds – corresponding with high school and college. Today, we’ve seen this in suicide clusters, like those explained in Life Under Pressure and The Years that Matter Most. Viewed outside the advancement angle from broader societal changes, we see that our teenagers and young adults have become The Anxious Generation. They encounter friction as they enter college as explained in The Coddling of the American Mind, as the protections and interferences of their families lose their influence.

Acting Out

They’re strange patterns. A daughter growing up in an alcoholic home marries an alcoholic. The son growing up under an overbearing mother marries a woman who’ll tell him what to do. The examples are endless, where some repressed trauma isn’t remembered or consciously considered but instead it’s acted out in their lives. Observation of this phenomenon goes back to Freud, who said that patients don’t remember, they act out.

Expendable Child

Sometimes children – rightly or wrongly – believe that they’re no longer needed or tolerated by the family. In this case, particularly when there are other children, the child may believe they’re expendable. Perhaps the thought is that they won’t miss them. Perhaps it’s “they’ll be better off without me.” In any case, the result is a risk for suicidality as they believe their life is no longer a good thing.

Problem Solving

In both children and adults, deficits around problem solving have been found in those who make suicide attempts. Retrospectively, it’s believed that those who die by suicide have problem solving deficiencies. The specific aspects of problem solving have been highlighted in terms of black-and-white thinking and the inability to generate alternatives.

We must expect that children (including adolescents) aren’t able to do good problem solving. The point of childhood and the protections that it brings is to help children learn how to solve problems.

No-Suicide Contracts and Self-Sealing Arguments

The use of no-suicide contracts has generally been discontinued, because they have no demonstrated efficacy. They make therapists feel good, but they don’t change outcomes. Basically, a no-suicide contract is a commitment on the part of a patient to not die by suicide. However, it’s coercive, and because of its coercive nature, it doesn’t feel like a commitment the individual made but rather something they had to do. Thus, it doesn’t create the kind of psychological barrier that will save lives. (See Principles of Topological Psychology.)

The recommendation in The Suicidal Child (which is wrong) is that a contract – or in this case, commitment – should be obtained; the failure to obtain such a commitment is an indication of high risk. This necessarily triggers the potential for inpatient hospitalization, which is problematic on multiple fronts. (See Your Consent Is Not Required and Rational Suicide, Irrational Laws.) Collaborative approaches like Managing Suicidal Risk do encourage a shared commitment, but it’s collaborative, not coercive.

The problem with automatically flagging risk for someone’s failure to be coerced is that it will quite likely make things worse.

The Presence of Love

The presence of a loving, accepting, and validating individual can change the trajectory of a child’s life. Unfortunately, some children can’t see these characteristics in their parents. It could be that they’re not there, but it’s equally likely that the child just can’t accept it. (See The Nurture Assumption and No Two Alike for more about these dynamics.) The power can’t be overstated. Everyone should try to lean in and to love The Suicidal Child.

Book Review-Half in Love with Death: Managing the Chronically Suicidal Patient

Robert Bogue September 3, 2025 No Comments

Most books about suicide draw little – or no – distinction between those who live with chronic suicidality and those who are acutely suicidal. Joel Paris in Half in Love with Death: Managing the Chronically Suicidal Patient draws a bright line between what works for the acutely suicidal person and what works for the chronically suicidal person. The line helps to delineate what activities might be appropriate or a bad idea for a chronically suicidal person and the acutely suicidal. That’s an important distinction, because half of people who die by suicide had no meaningful contact with the mental health system.

The Drivers

Paris illuminates in the introduction that chronically suicidal are driven by:

Psychic pain (see Suicide as Psychache)
Emptiness (see Man’s Search for Meaning and Loneliness)
Hopelessness (see The Psychology of Hope)

He explains that suicidality is the person’s attempt to cope with these states of mind.

Fear

Paris, in the introduction, explains that a therapist’s greatest fear is losing a patient to suicide, then spends much of the book explaining how the therapist must come to terms with their fear of losing a patient to suicide. There are, unfortunately, practical considerations related to malpractice lawsuits to consider – but as Rational Suicide, Irrational Laws explains, the concerns aren’t as large as therapists see them. However, the natural aversion to losing anyone to suicide and the concerns about their own competence if they lose a patient to suicide are significant drivers as well.

When I’m speaking about fear, I often reference Richard Lazarus’ work in Emotion and Adaptation. He explains fear (and stress) as a cognitive appraisal rather than emotion, and that probability and impact drive the chances of fear higher, while coping capacity drives it lower. Paris doesn’t directly address how people can confront their fears about losing a patient, but books like Find Your Courage and Braving the Wilderness directly speak to the need – and the meaning of the vulnerability that the courage requires.

The problem is if therapists don’t address their fear, they’ll do things that harm society or their patients. They will decide not to take patients with suicidal thoughts, forcing them to either suffer without treatment or lie about a very real concern in their life. If they do accept the patients and move too quickly towards inpatient hospitalization, they’ll send a strong message that the patient can’t deal with their problems on their own and may, separately, make recovery more difficult, as the hospitalization disrupts their freedom, autonomy, their social network, and their employment. Addressing therapist fears is critical to them being able to serve their patients and the broader community.

The Paradox

For many who live with chronic suicidality, the thing that keeps them alive is the possibility of death – death by suicide. This apparent paradox is resolved with awareness that the option of death means that no matter how difficult life gets, there’s always an escape. We see this paradox play out in those with terminal illness who have been granted the means of suicide. While people pursue the sometimes arduous process, they’ll rarely use the means they’ve been granted. (See Rational Suicide, Irrational Laws, Undoing Suicidism, and November of the Soul.) What sense does it make to invest the effort if you’re not going to take advantage of the results? The answer lies in the world of possibility and choice.

For the chronically suicidal, their life isn’t in a state where they’re sure they’ll want to live until their natural death. The concept of suicide offers safety relief if things get too bad. In Managing Suicidal Risk, David Jobes explains that, in the CAMS approach, the goal is to work together to find a way to make life more desirable – rather than trying to take suicide off the table forever, at least initially. (See also Marsha Linehan’s Building a Life Worth Living.)

The fact that, for the chronically suicidal, suicide must remain an option – an undesirable option – creates the requirement that therapists deal with their own discomfort and fear.

The Nothing

In the 1984 film, The Neverending Story, a boy must save the world from the Nothing. It is a blackness that threatens to overtake everything. In the lives of the chronically suicidal, it’s as if the Nothing has been inside of them. They, according to Paris, don’t believe that their best is over or is yet to come but rather there is no “best” and no meaning for them. (See also The Time Paradox for perspectives on time and “best.”)

In the summary above, I include both Man’s Search for Meaning by Viktor Frankl and Loneliness as additional references. Both only proximally address the kind of emptiness that Paris is describing here. Loneliness is characterized by a lack of social connections but operates only in the realm of social connections. Man’s Search for Meaning describes how Frankl processed the realities of the Nazi concentration camp that he was detained in. It certainly expresses the despair and the way that the prisoners were brainwashed into believing they were subhuman. However, this, too, is an external force working on the psyche of the individual.

With the emptiness that Paris describes, the force flows from the person into the outside world. They see no (or little value) in themselves. They’re looking for something about themselves to attach identity to, but they’re struggling to find it. It’s not like they’ve necessarily encountered stigma that Erving Goffman describes in his book, Stigma: Notes on the Management of Spoiled Identity. It’s like they’ve self-stigmatized or have been unable to find an identity to spoil.

The Statistics

There is one bit of challenge to Half in Love with Death, but it’s a reasonable one. The statistics that Paris shares regarding the prevalence of suicidal ideation are, I believe, substantially understated. Going back decades, we see point-in-time estimates of suicidal ideation at 33% or greater. In more recent surveys of high school teens, the rate of single-year suicidal ideation exceeds 25% and lifetime can exceed 50% – in high school. To be fair to Paris, I think there’s a societal shift that’s happening, in part because of weakening suicide stigma in general and in part due to generational shifts. I liken this to the initial confounding results that Amy Edmondson encountered, where reports of incidents increased immediately following efforts to improve the psychological safety in a healthcare setting. It wasn’t that the actual prevalence of incidents increased: they were safer to be discussed when before they hadn’t been. Ultimately, this allows the incidents to be resolved – even if it’s discomforting in the short term to see the tracked metric increase.

I mention this, because in the cluster of research that Paris shares, the lifetime suicidal ideation rate ranges from 9% to 17%. This cannot possibly be the case. In the United States in 2003, the lifetime prevalence of suicide was 1:87 – or about 15%. It’s hardly possible that the lifetime rate of suicidal ideation is below the actual fatality rate.

Similarly, the rates that Paris uses for the number of suicide attempters who will eventually die by suicide is 3-7%. This is lower than the generally accepted rate of 10%. It’s possible that Paris’ estimates are more accurate. Here, however, the point is that the number of people who have made an attempt and will eventually die by suicide is still low – despite the fact that prior attempts is one of the most highly correlated factors with eventual suicide death and further attempts. (See Myth: Once You’ve Made an Attempt, You’ll Eventually Die by Suicide.)

Paris does affirm the conclusion that suicide screening cannot be sufficiently sensitive and specific to be useful in practice.

Non-Suicidal Self Injury (NSSI)

On the surface, self-injury is the same. However, there is a key difference in intent. NSSI is intended to provide some relief from psychological pain. As strange as it may sound, self-harm provides both a way to ensure you can still feel and a distraction from the psychological pain that someone may be feeling. Self-injury can feel soothing – and can become addicting. However, none of this is to say the person wants to die by suicide. NSSI is a coping mechanism just like drugs, alcohol, and more positive coping mechanisms.

The relationship between NSSI and suicide death is small, as I mentioned in my review of The Prediction of Suicide. There is some correlation, and it may be related to Thomas Joiner’s Interpersonal Theory of Suicide, which proposes that capacity for suicide impacts outcomes. The more comfortable someone is with self-injury, the more comfortable they may become with lethal self-harm.

Myths of Suicide Prevention

Paris dedicates a chapter to suicide myths; unfortunately, in the chapter, he propagates a few.

Quoting Goldney from a 2000 book, Paris says, “The sobering reality is that there has not been any research which has indicated that suicide can be predicted or prevented in in any individual.” This is indeed a myth still. See Myth: You Can Tell Who will Die by Suicide by Their Appearance, Myth: Suicide is Never Decided Suddenly, Myth: People Are Either Suicidal or Not, and Myth: Every Suicide Attempt Has Warning Signs.

Conversely, Paris starts with, “Since almost everyone who dies by suicide suffers from a mental disorder…” before discussing the failure of mental health interventions to change outcomes. There could be a reason in that the relationship between mental illness and suicide is substantially overstated. See Myth: Those who Die by Suicide Had a Mental Illness.

Paris relays that medicine packages can change suicide rates (which is true). Reducing quantities and moving to blister packs did reduce suicide attempts in the UK. Similarly, recent news shows that the suicide prevention net on the Golden Gate Bridge is substantially reducing rates. This and other research expose the Myth: If We Restrict One Means of Suicide, They’ll Just Pick Another.

He also calls into question the famous caring contacts intervention by Motto and Bostrom, which tested sending letters to those who refused clinical follow up after hospitalization. The letters only expressed concern for the patients’ wellbeing, but the results were impressive for a simple intervention. Paris notes that the sample size was small, the effect was small, and the research has never been replicated. Such a low-cost intervention does deserve further follow up.

Trajectories

It’s important to recognize that just because someone experiences trouble in their adolescent years doesn’t mean that they will eventually die by suicide – or even struggle as an adult. This awareness doesn’t need to come from the Harvard Study of Adult Development – but it does. The same comes through in Delinquent Boys. Not everyone who was standing on the street corner ended up there years later. Many of those who seemed the most troubled grew up to be the most productive members of society.

Emotional Dysregulation

It’s a fancy way of saying that they’re not able to control – or shape – their emotions. The results are often bad and sometimes tragic. When people can’t regulate their emotions, they can enter a downward spiral, like those described in Capture. Paris’ description calls it emotional reasoning – basically a form of reasoning that isn’t directly connected with rationale or reality. It’s the perception – colored by emotion – that makes it difficult for them to see the positives of life. Shneidman considered the limitations of cognition – the narrowing – to be cognitive constriction. (See The Suicidal Mind for more.)

With tools for emotional regulation, maybe it would be possible for people to avoid becoming Half in Love with Death.

Book Review-Rational Suicide, Irrational Laws: Examining Current Approaches to Suicide in Policy and Law

Robert Bogue September 2, 2025 No Comments

I was sitting in a semi-rural county’s sheriff’s training center on the third day of a Crisis Intervention Team (CIT) training. I was wondering what the standard was for an officer to detain and transport a person for psychiatric evaluation before a judge was to teach the officers – and me as the only community member – what the standard was. Had I read Rational Suicide, Irrational Laws: Examining Current Approaches to Suicide in Policy and Law, I wouldn’t have been so surprised at what I was about to hear. What I expected to be clear rules and consistent rulings turned out to be a morass of confusing and conflicting laws, decisions, and opinions.

I began to learn that the standards – such as they were – could be interpreted very widely with very little, but some, consequences for interpreting things too broadly.

Signals of Caring

I read Rational Suicide, Irrational Laws on the heels of Your Consent Is Not Required. It was enough of the legal positioning that it nudged me into this work – which I’d long wanted to read. The result is that I realized one of the most important things in the process – no matter what the laws, court cases, or law enforcement say – is caring. Anything that signals caring to the person who is suffering is like a beacon they cannot ignore. Conversely, they can’t avoid observing that the inpatient psychiatric facility they’ve just been incarcerated in has paint chipping off the walls and broken furniture.

One of the biggest opportunities that we have as a society is to signal our caring and concern for people whose lives are filled with such suffering that they painfully consider suicide as an answer.

Glad to Be Alive

Survivors who have jumped from the Golden Gate Bridge often say that they realized immediately after jumping that everything in their life was solvable – except for having jumped. (See The Suicidal Mind and Myths about Suicide for more.) More generically, a small percentage of people who make an attempt go on to die by suicide. Research numbers vary, but clearly less than 15% of those who make an attempt go on to die by suicide.

Many people who make an attempt are glad they failed.

Mental Health and Suicide

The relationship between mental health and suicide is complex – and from the perspective of the law, problematic. As I mentioned in my review of Your Consent Is Not Required, involuntary detention requires both mental illness and dangerousness to self or others. Some states have include gravely disabled in that bucket of dangerousness if they don’t appear to be able to care for themselves. This problem is that the Supreme Court was clear that one must be both dangerous and have a mental illness. Some people still cling to the mistaken belief that suicidality means mental illness despite compelling evidence that this isn’t the case.

Thus, the result is that law enforcement should not – but still often does – detain people for suicidality alone. The standard that’s used for detention is “reasonable,” the lowest standard of evidence. Given that law enforcement aren’t mental health experts and the people they engage with are often in crisis, which mimics many symptoms of mental illness, it’s reasonable that they seek a mental health professional’s determination – or not – of mental illness.

The problem is that too many mental health professionals are ready to diagnose a mental illness in the lack of solid evidence to get someone committed. And complicating this further is that the standards for diagnosis in the DSM are notoriously broad, meaning that a person could see two mental health professionals and rarely get the same diagnosis.

Can’t Get In, Can’t Get Out

One of the perverse irrationalities about inpatient psychiatric facilities is that they are hard to get into – and hard to get out of. There are numerous, but anecdotal, reports that people can’t get into an inpatient psychiatric facility unless they’re willing to express suicidal ideation. If they’re presenting with legitimate mental health needs – that can be helped with short-term inpatient hospitalization – they are unlikely to be admitted. However, that all changes if they hint at suicidal thoughts.

Once in the facility for expressing suicidal thoughts, they may find it difficult to get out. Involuntary detention at the facility may be hard to terminate even though there are supposed to be legal safeguards. If a psychiatrist claims that your belief that you don’t have a mental illness is a side effect of your mental illness, what do you do? In many cases, the courts accept the psychiatrist’s testimony – and deprive you of your civil liberties.

Some may have noticed that I used the word “detention” for being in an inpatient psychiatric facility, a word normally reserved for prisons and jails. I do so intentionally because there’s no evidence that inpatient psychiatric hospitalization has a therapeutic effect.

Community Support

In contrast to the lack of evidence for inpatient psychiatric hospitalization, we do have evidence that some community programs do make a difference. Emergency rooms, where most people are transported for evaluation, are some of the highest cost services that we have in any part of the healthcare and behavioral healthcare systems. Community programs – which often involve volunteers – are some of the lowest cost and most effective programs that we have.

The problem is that the outcome of an emergency room visit is either inpatient psychiatric hospitalization – or discharge without follow-up. Called case management or continuity of care, helping the patient find the resources in the community that could prevent them from needing the emergency room again rarely happens. (See the SPRC article Continuity of Care for Suicide Prevention and Research.)

Perverse Incentives

It’s been 25 years since I first saw the systemic problems with our healthcare system in the US. We were working on better care for patients with diabetes – and it was a hard sell. Managed care plans knew that preventative care was better, less expensive, and had better outcomes. However, they also knew that the rate of change was so high that the likelihood that they’d have a patient next year or the year after – when their investments would pay dividends in the lives of the patients – was low. So, we struggled to get organizations to do the right thing – counter to their incentive structures.

One of the challenges in care are the lines between insurance authority, provider expertise, and patient rights. Can an insurer require that a patient take a medication prescribed for the patient’s visit to be covered by insurance? Broadly, we know that patients have the right to refuse treatment – except for psychiatric treatments. So, what happens when a psychiatrist prescribes medication that the patient refuses to take? Can insurance refuse to pay for the whole encounter? Should a provider threaten a patient, saying they must take the prescribed medication or insurance won’t pay?

Competence and Liberty

The Mind Club frames the conversation in terms of who we should defend and who we should hold accountable. It’s expressed as the degree to which someone (or something) has thoughts and feelings and the degree to which they have agency. The law’s approach and standards are different, fundamentally tangling competence with liberty. Those who have experiences and the ability to reason should be held accountable and trusted with liberty. When people can no longer comprehend good versus bad, their liberty should be surrendered for the good of society.

The Supreme Court must help us navigate the balance of the civil rights of the individual compared to the responsibilities of the state to protect its citizens. Because of this, the court is careful when considering places where the state might have a reasonable need to interfere with a person’s liberties. Thus far, the court has held that restrictions to individual rights – particularly their liberty – must be constrained to a narrow set of circumstances.

The courts have generally held that a person is considered competent until it has been shown otherwise. Thus, when we’re discussing the ability to confine someone to an inpatient facility, the state must first show that they’re no longer competent – which should be harder than it is.

Criminal Assist to Non-Criminal Act

While suicide itself has been decriminalized, assisting a suicide is still sometimes a criminal act. This strange twist is justified by the concern that someone might encourage a suicide that the person might not otherwise do. In short, while the law may accept a person’s right to self-terminate, that doesn’t mean anyone necessarily likes it.

There is still a stigma attached to death by suicide, whether it’s illegal or not. (See Stigma for more about what stigma is.) There’s still an ongoing conversation in the US about who should be allowed to assist someone in dying and what does – and does not – cross the line. While some states, like Oregon, specifically explain what is necessary to get the right to die (“Death with Dignity”), not every state has. Even in Oregon, it’s possible that someone with the same consequences – except having complied with the rules of the act – might be involuntarily treated and revived.

In other states, the question becomes whether an assisted suicide can be done by a physician or not. Additionally, the degree to which someone can assist is an open question. Is it assisted suicide if you hook someone up to a machine that they can use to end their own life, as Jack Kevorkian did? What if you just acquire the resources that are needed to die?

Does it help to be a family member of the person? Or does the potential gain to be had from the death make it more likely that you’ll get wrapped into a criminal indictment?

Undoing Suicidism explains the value of assistance – with appropriate safeguards – and the problems with the uncertainty that drives people to end up with an attempted suicide resulting in substantial disability instead of a death surrounded by friends and family.

Illegal Attempts

In a peculiar twist, some places still have suicide attempts on the books as a crime even though suicide itself has been long removed as a crime. Nevada recently changed its laws, while North Carolina and Virginia have laws on the books that criminalize an attempt – even though suicide itself is not criminalized.

However, even with suicide attempts being on the books, few jurisdictions will prosecute. Perhaps this is in part because they know that they’ll likely not get a jury to convict. Juries have repeatedly demonstrated that they will not hold people accountable to laws they can’t understand.

How to Not Get Sued

Stefan states, “Mental health professionals are not sued for their decisions or the outcomes of their decisions, but for the process (or lack of process) by which the decision is made.” This is consistent with Skip Simpson’s view in The Suicide Lawyers and Shawn Shea’s perspective in The Practical Art of Suicide Assessment. Both strongly encourage documentation, with Shea providing a specific framework for doing so.

This seems counterintuitive. Shouldn’t the outcomes – or at least the decisions the provider made – matter? The answer comes from the reality that we cannot control the outcomes. While it’s reasonable for heirs (family) to be angry at the death of their loved one, that’s not a legal standard. Similarly, decisions are based on the result of prediction of the patient’s behavior – and it’s clear that even the best clinicians aren’t good at predicting future patient behavior. What we’re left with is the ability to say whether someone met professional standards for documentation.

Strangely, clinicians who know they are working with suicidal clients are not generally sued for failing to use a research-proven approach to their care. We have B-CBT-SP, CAMS, and DBT as validated options for treatment, but clinicians aren’t sued even if they don’t use any of them.

Dying, Fast and Slow

Smoking is legal in the United States despite the very clear, negative impacts to health. It can be accurately described as killing yourself slowly. Similarly, large quantities of alcohol have their own negative impact on lifespan, and it’s completely legal for adults. As a society, we seem to have decided that it’s acceptable to kill yourself slowly.

It gets a bit less clear as we move to people who hasten their death by failing to drink or eat. Officially, patients who have no mental illness can refuse any treatment – including food and water – but sometimes doctors will ignore these desires like they’ll ignore advanced directives like do not resuscitate (DNR). In the absence of a mental illness, if it comes to a legal fight, they’ll likely lose.

However, it is acceptable to the legal system for those who are not competent to be ordered to accept treatment. The sticky point comes when we compare the standard for competence against suicidal thoughts. While some would argue that suicidality is prima facie evidence of a mental health issue, most people would disagree today. More importantly, even if there was a mental illness, not all mental illnesses confer a lack of competence. In short, for most conditions, suicidality isn’t sufficient cause for someone to be forced into treatment – consistent with the Supreme Court rulings. However, we never know because, in the end, we’re faced with Rational Suicide, Irrational Laws.

Book Review-Building a Therapeutic Alliance with the Suicidal Patient

Robert Bogue September 1, 2025 1 Comment

There was a think tank-style meeting in Aeschi, Switzerland about what could be done to improve suicide prevention. The meeting spawned others that ran for some time but have unfortunately come to an end. There were a number of things that came from these meetings. From what I can determine by those who went, they were a sort of magical event that doesn’t normally happen. Building a Therapeutic Alliance with the Suicidal Patient is one of the outcomes of these meetings – and it’s a comprehensive look at how to be effective at treating suicidal patients. While it’s aging, it’s aging well. Conceptually, the important points raised in the book remain important to prevention today. To understand why, we need to go to the roots upon which the book is built.

Carl Rogers

The ideas that Carl Rogers shared were radical for his time. He intentionally leveled the playing field between therapists and patients. He suggested that patients were experts in their own lives and that, while therapists brought their own expertise, it wasn’t more important than the patient’s experience. (See A Way of Being.) He also said that therapists should have unconditional positive regard for patients. That is, they should suspend their judgement and remember that their patients are important people, too.

Rogers’ work wasn’t universally adopted in therapy, but thankfully it has reverberated through time.

Motivational and Narrative Interviewing

If you want to find a way to work with difficult patients, substance use disorder (SUD) is a good place to start, because their behaviors are notoriously persistent. Building on Rogers’ work, Miller and Rollnick developed what would be called Motivational Interviewing. It’s a strategy that is widely respected in SUD recovery circles because it works.

While motivational interviewing has specific approaches and techniques, it is consistent with the approach of the Aeschi group – who call theirs a narrative interview – which is quite different than the way that most suicide assessments are done. Instead of reading off a checklist of standard questions, they simply ask the person to tell their story.

Motivational interviewing tools like eliciting, affirmation, and summarizing are good tools in service of the narrative interview to help the patient know that you’re listening and trying to understand.

Letting people tell their story is also consistent with the work of James Pennebaker. He showed the value of creating a narrative and telling a story (or writing it down). (See Opening Up.)

Standards of Care

Every therapist has something they’re doing now. It’s something they were trained in. It’s something that some well-intended person insisted works. However, despite the assurances and the good intentions, a lot of what is done in therapy isn’t supported. The Heart and Soul of Change explains what does work – and, largely, it’s building a therapeutic alliance. Science and Pseudoscience in Clinical Psychology is a bit more critical, highlighting some of the challenges. While many therapists lament poor reimbursement rates and limits to the number of sessions, the simple fact of the matter is that the efficacy of therapies varies wildly.

Screening and Assessment

Before we go further, it’s important to acknowledge that the standard practice today includes two things that have poor predictive capacity for suicide attempts and deaths. They are screening – using any tool – and assessment by even trained clinicians. That is to say that we don’t have any reliable predictor of when someone will die by suicide even when evaluated by a clinician.

This is important, because we have no guarantees and no safety net. When a patient decides to die by suicide, they can. As Craig Bryan points out in Rethinking Suicide, prediction may never be possible. The rapid, event-driven changes in suicidal intensity may be something that we simply need to live with. While it’s essential that clinicians are able to create a therapeutic alliance with the patient, there are no guarantees.

This has important implications, because the death of a patient to suicide is seen as prima facie evidence that the clinician has done something wrong – as if they have the power to prevent a death by suicide. (See The Suicide Lawyers.) But clinicians can’t stop a dedicated patient – even in an inpatient setting. (See Suicide: Inside and Out.)

Disposal

Screening in emergency departments is often seen as a way to dispose of the problematic suicidal patient. Patients with several attempts may earn the derogatory moniker of “frequent flyer.” Emergency room staff believe they are there to treat “real” patients who are experiencing illness or trauma – not patients who are suffering from suicidal ideation and actions. The process of screening patients allows for them to be shuttled off towards inpatient psychiatric commitment – effectively disposing them out of the emergency department. The admission of a serious suicide attempt is often sufficient to proceed to have someone committed.

Commitment laws vary from state to state, but based on the guidelines set by the Supreme Court, a person must be both mentally ill and a danger to themselves or others to qualify for involuntary psychological detention. In Indiana, where I live, the rules around self-harm are codified as gravely disabled. On the mental illness side, it becomes more tenuous. Mental illness diagnoses are based on the DSM-5-TR, but the interrater reliability (the chances two people will get the same answer) is very low. Many believe that if you’re suicidal you must, by definition, have a mental illness – despite evidence to the contrary. (See Myth: Those Who Die by Suicide Had a Mental Illness.) This whole topic is well covered in Your Consent Is Not Required.

Therapy Defection – or Not

What are the set of variables that mediate whether a patient will stay in therapy – and presumably be responsive to the therapy? The answer is one that Marsha Linehan, who was a part of the Aeschi gatherings, recognized in her work with patients with borderline personality disorder. Dialectical behavior therapy (DBT) is based on the notion that a therapist must simultaneously – or at least alternatingly – validate the patient’s current state and thinking while advocating for change. (See Cognitive Behavioral Treatment of Borderline Personality Disorder.)

Directly, the factors that are related to listening and alliance building (such as sensitivity, listening, understanding, attitude and expertise) mattered when it came to keeping patient in therapy.

While the book cites evidence of early alliance had a negative effect. However, this makes sense to me from the perspective that the reported early alliance may be fake. It can be that the patient wants the therapist to approve of them, so they’re answering the alliance questionnaire more positively than is real. When there are stressors to the alliance, it crumbles. Linehan’s approach in DBT of directly moving for change leads to continual testing and refinement of the alliance and assurance that the perception of its stability is supported in fact.

Attachment

The book makes the point in several places that the therapist is fulfilling a role not unlike that of an attachment person (mother or father) by increasing the perceived safety such that the patient feels comfortable exploring on their own. There’s some support for this conceptually from attachment research. In Attachment in Adulthood, it’s explained that children’s attachment can be shifted towards secure with good foster placements. Adults in intimate relationships with a partner who is securely attached move towards secure attachment. So, we know from the attachment research that improving attachment is possible. It’s reasonable to believe that a therapeutic relationship with a clinician can help move people towards secure attachment and the benefits that come with it.

Induction and Promotion of Hope

One of the factors that is consistently correlated with suicidal ideation and attempts is a sense of hopelessness. Most people don’t understand hope. They believe that it’s a feeling, but as Rick Snyder explains in The Psychology of Hope, it’s a cognitive process. It’s the combination of our sense of how to accomplish the change and the willingness to do the work. This is often called willpower and is the subject of a Roy Baumeister’s book, titled Willpower. Marty Seligman in The Hope Circuit reviews the work of his career and reframes his original concept of learned helplessness as a failure to learn hope.

Hope is both an essential tool in fighting suicide and one that is often difficult to induce and promote in people.

Blame and Shame

One of the more common approaches to working with suicidal patients is to blame them or shame them. While this is not a desirable situation, it is unfortunately too common as we see in the emergency room example above. This was the strategy that was used for decades with SUD work. After decades of research on SUD, we discovered that using blame and shame don’t work. It’s not surprising if we look at the work of Bruce Alexander as described in The Globalization of Addiction, which speaks to how the original “rat park” experiments relied on social isolation of the rats – who are social creatures. Chasing the Scream looks not only at the problems with blame and shame but also how we criminalized behaviors that would previously have not been criminal.

The Aeschi approach is structurally designed to avoid the unintentional affliction of blame and shame. Instead, the patient is intentionally validated for their perception of their world.

Fighting the Righting Reflex

Motivational interviewing calls the tendency to “make things right” the righting reflex. It shows up as a desire to tell others what’s right – and it’s nearly universally wrong. In the case of a suicidal patient, it shows up as the desire to correct the desire for suicide. After all, in the therapist’s view, it’s not right. The problem is that this is a severe form of invalidation that can sever any therapeutic alliance that has been generated.

Coherent Narratives

According to Ed Shneidman, a person who could write a meaningful suicide note would not be in the position to complete a suicide. Shneidman was no stranger to suicide notes: his career included extensive work trying to find answers in the notes that suicidal people left behind. In Clues to Suicide, he explains how banal and disconnected they are. He also spoke of cognitive constriction and the inability to fully consider a condition as a part of suicide. It can be that he’s saying the ability to write the note would communicate that the person isn’t in a state of mind consistent with the minds of those who are suicidal.

Sick Cycles

In The Moment It All Starts to Unravel, I share some of the work of relationship experts, including the idea of a sick cycle. It’s a cycle that’s kicked off by one bad behavior that fuels another behavior and so on. Not only does it occur as I explained it in intimate relationships, but it can also occur in any kind of close relationship, particularly when a self-injurious or suicidal behavior occurs.

Experiencing real or imagined threats to the close relationship, the patient engages in self-injurious behavior, which alienates the attachment figure. It may be because they feel betrayed or a lack of control or whatever, but their instinct is to pull back. The patient, rightly, perceives the retreat, which further threatens the attachment – which can lead to further acting out.

When the person in the relationship is the therapist, they’ve got a professional, ethical obligation to stay. However, when the other person is a spouse, a relative, or a friend, the requirement to tolerate the discomfort and continue in the relationship is less strong. Many people who have had chronic suicidality have been in this cycle for a long time. (See Loving Someone with Suicidal Thoughts.)

While therapists have an obligation, it doesn’t make it easy to bear the escalation of patient self-harm intensity nor the implied responsibility to prevent it.

Psychache

Shneidman’s word for mental pain was psychache. (He wrote a whole book on it, Suicide as Psychache.) Referring to the work of Orbach, Mikulincer, Sirota, and Gilboa-Schechtman, the book uses their definition: “Mental pain is an irreversible sense of hurt that arises from the perception of negative changes in the self, which is imbued with extremely negative emotions and cognitions.” They provide an alternative definition from Roy Baumeister’s work as well: “Mental pain as a self-disappointment due to a discrepancy between the ideal and actual selves”

The Unslayable Dragon

It’s described as “the monstrous enemy of the suicidal patient, which cannot be fought alone.” I prefer to think of something more concrete. I see the suicidal state of mind as a dragon that cannot be slain – it can only be subdued for a time. Each battle with the dragon either strengthens it or weakens it.

The goal is to give the suicidal person the tools they need to subdue the dragon in a way that becomes easier for them and further weakens the dragon. Some of the tools may be better armor in the form of protective resources, some may be in better agility by realizing when the dragon is ready to rear its head, and some may be in the form of better weapons to fight with.

The dragon gets stronger when we continue to get triggered.

Making the Implicit Explicit

One of the challenges is that we live in a world where much of what we believe is implicit. We have never tried to articulate it. (See Lost Knowledge for more on implicit and explicit and articulation.) One of the goals of helping anyone is to help them convert their implicit thoughts, feelings, and beliefs into something explicit that can be worked with.

Creating a place of explicit beliefs is core to Building a Therapeutic Alliance with the Suicidal Patient.

Suicide Prevention Month

Robert Bogue August 29, 2025 No Comments

As the sweltering weather of summer fades and the trees begin to change color, we enter Suicide Prevention Month. Every year, we gather reading from the last 6 months to offer our voice toward suicide prevention efforts across the world.

Starting this US Labor Day, for the first two weeks of September, we’ll publish a book review every day on suicide-related topics. This year, we discuss suicidal patients, including children and teens, the impact of policy and law, and one of the most well-known novels on suicide – among other topics.

For more information about the steps we’re taking to prevent suicide, visit RobustFutures.org. Learn more about the prevailing myths (and the truths behind them) at SuicideMyths.org.

ACMP The Standard for Change Management 2.0 Release

Robert Bogue August 27, 2025 No Comments

Yesterday, ACMP released version 2.0 of The Standard for Change Management, and I’m proud to share that I served on the steering committee for this effort. This revision has been a long time coming since the first edition was released in 2014. My journey with supporting the revision started on a rainy day driving back from a conference and a short visit with friends. It was a few years ago when Greg Voeller called to say that he’d appreciate my support in the revision work. He was committed to this process enough that the professional committee of the board formed a separate committee for steering the revision of the Standard.

We’d spoken before about the work I’d done with CompTIA and Microsoft on some of their certifications. I’ve obtained many more but had a hand in certifications from both organizations. (If you’re curious, some of my certifications are on my Credly profile page.) We talked about the move to strictly adhere to the ISO standards for the development of certifications and the desire to provide more rigor to the revision process. My experience was different from the rest of the team, and the breadth would provide some context for the work.

The revision addressed some of the concerns from the first version of the Standard, including the standardization of the artifact names. What I’m most proud of is the chance to be a part of the immense team of amazing, talented volunteers who contributed to making The Standard 2.0 what it is. I appreciate the opportunity to contribute to moving this important work forward.

Book Review-Stress, Appraisal, and Coping

Robert Bogue August 25, 2025 No Comments

Central to everyone’s life is how they deal with stress through appraisal and coping. Richard Lazarus and Susan Folkman’s classic, Stress, Appraisal, and Coping, explores what stress is, how we appraise its impact on us, and how we cope. When I first read Emotion and Adaptation, I was struck by a central idea that our emotions are cognitively assessed. This idea, validated by many, has formed the basis of our work to help people understand fear and stress. Getting a chance to return to the concept and work through its details was a welcome journey.

What It Isn’t

In a strange turn, the preface indicates that this work is intended to be neither an undergraduate text (textbook) nor a self-help book. The work is intended for “professionals in many disciplines who might appreciate an integrative theoretical analysis of the subject matter.” In making this statement, they eschew the primary ways to make money with a book – and make it clear that the goal is to educate, inform, and engage with people who are truly interested in the material.

Stress and Coping

To be effective in this discussion, we must agree to a set of terms. “Stress” is used so pervasively that barely any meaning is left. In Why Zebras Don’t Get Ulcers, Robert Sapolsky explains the levels that stress operates on and tries to operationalize the impacts. The book moves from the classic biological views of Hans Selye in The Stress of Life to the neurological impacts of sustained stress. However, there’s still a need for greater clarity.

It starts with a stressor. A stressor is some part of the environment that presses on an organism. I often use the classic example of a lion as a stressor. If I become stressed, I’m speaking about the impact of the lion on me. I’m speaking about my physical and psychological response.

Stress itself breaks down into two forms: helpful and harmful. In Antifragile, Nassim Taleb explains how we need stress and challenges in our lives to allow us to grow and become more capable. “Eustress” is the word used for normal, beneficial stress; the beneficial qualities are based both on the overall circumstances and the characteristics of the person. Lazarus and Folkman speak of increasing capacity for stress through stress inoculation, training people to accept larger stressors through the gradual increase of stressors and, therefore, stressful situations.

Appraisal, for Lazarus and Folkman, comes in two waves. Primary appraisal assesses the stressor and determines whether it is irrelevant, positive, or negative. Negative appraisals warrant a stress response. The secondary appraisal is about how to respond to a potentially negative stressor. It’s an evaluation of the kinds of coping strategies that should be employed and an assessment of the relative capacity to neutralize the threat.

In problem-focused coping, we activate coping strategies to neutralize the threat. An example may be studying when faced with uncertainty on an important test. An emotional coping strategy might focus on distraction to suppress the anxiety of the uncertain outcome. In the test example, it may be that the person feels that there are no problem-focused strategies like studying that will lead to better outcomes. Instead, they must accept the uncertain outcome and work to dampen their anxiety about the outcome.

Lazarus demonstrates that these two strategies are chosen differently. When surveying students before a test, he discovered more problem-focused solutions (e.g. studying). When surveying students after the test but before the grades were posted, he discovered more emotional-focused strategies (e.g. distraction), since the outcome was no longer something that could be influenced.

Optimal Level of Arousal

In my post, Why We Need Stress, I explained the case for stress. While we often look at stress as a negative, we need to acknowledge that we can’t live without stress, either.

While Daniel Pink in Drive derides the value of stress in creative decision making, there’s a long history of study on the role of stress in learning. In How We Learn, it’s referred to as desirable difficulty. Mihaly Csikszentmihalyi in Flow explains that the powerful state of performance is driven by the balance of challenge (stress) and capability.

There’s an old Scottish proverb, which was recounted in Trust, that explains how hardworking families build wealth, and by the third generation, that wealth is lost. Well-intended parents shield their children from struggle, which prevents them from building the skills necessary to face challenges when they come. We need stress to survive and to thrive.

Psychological Safety

In my review of The Fearless Organization, I was critical of the singular focus on organizational dynamics. This focus ignored the fact that safety is a perception that exists beyond the environmental conditions that an organization creates. It argued that people will bring things with them that make them feel unsafe even if the organization strives to create a safe environment. One component of this is the way that they evaluate stressors at the organization based on their coping capacity. The other dimension is the general sense of fear that they bring with them.

Our responses aren’t as rational as we’d like to believe. In The Honest Truth About Dishonesty, Dan Ariely recounts the research that says a judge’s degree of hunger (based on time of day) will impact your chances for parole. Vance Packard in The Hidden Persuaders and Richard Thaler and Cass Sunstein in Nudge speak about how small things can persuade us to do something – or not. Our overall mental state impacts our appraisal of new environmental factors that may become stressors.

Reinforcing Loops

As we begin to see the world as more hostile, lonely, and toxic, we evaluate each new experience not from neutrality but with a bias towards negativity. This bias further reinforces the negative worldview. This is the kind of reinforcing loop that Donella Meadows in Thinking in Systems warns could lead to tragic outcomes. David Kessler in Capture explains how these negative thoughts can capture our thinking in a way that makes it difficult to see the broader picture.

Anxiety

Anxiety is a response to a world that we struggle to predict. Fundamentally, anxiety is an acknowledgement that there may be a stressor we cannot anticipate and this stressor may exceed our coping capacity. We feel powerless to see and avoid or confront the impact of life’s challenges. A way to provide a coping skill is to develop self-agency, which mitigates both the unpredictability and the capacity to respond.

Freud gave anxiety a central role in psychopathology – but in doing so, he missed the critical precursor, trauma. Professionals have struggled with trauma. While “shell shock” was acknowledged after the first World War, it was seen as a weakness. It wasn’t until 1980 when trauma was recognized by DSM-III. Our understanding of trauma and its impact on mental health continues to evolve. We struggle to define what psychological trauma should be and what conditions lead to people what DSM-V-TR calls “complex PTSD.”

One of the normal outcomes of repeated exposure to trauma is hypervigilance – said differently, anxiety. What Freud saw as anxiety may have been a hypervigilance brought on by trauma. (See The Assault on Truth for one kind of trauma that Freud may have been trying to avoid discussing.)

Stress as a Rubric

Rather than viewing stress as a single-dimension valuable, we may need to look into the diversity in the concept. Consider food allergies. Some people are allergic to gluten, which is found in many grains. Some are allergic to shellfish or peanut butter. This doesn’t mean the person is bad. They just have a specific sensitivity to their environment in terms of what they ingest. It also doesn’t mean that gluten, shellfish, or peanut butter are bad. The problem surfaces in the intersection between the person’s sensitivities and the environment’s characteristics.

Representing stress as a number from zero to ten, how might we rate a peanut butter sandwich? A person who doesn’t have an allergy to gluten or peanut butter might rate it as zero. A person who is allergic, depending on the degree of sensitivity, may regard their stress as ten.

Using another analogy that relies on context, but not the person, consider a bullet. Other than the presence of lead, are bullets inherently stressful? For most people, not inherently so. They can touch a bullet with no concern for their physical welfare. Conversely, when fired at us from a gun, bullets are both stressors and a threat to life.

The material object – the bullet – didn’t change. What changed is the anticipated results and our perceived capacity to cope.

Now consider that you’re wearing bulletproof armor. You know the bullet being shot is one the armor is designed to stop. How does this change the perception of the threat?

So, in some cases, the factors that drive stress and fear are direct interactions between the person and the environment. In other cases, the degree of stress is driven by the interaction between two or more aspects of the environment and how they may impact the safety of the person.

Defensive Reappraisal

You can’t change what happened in the past, but you can reappraise what it meant. You can look back on previous stressors with a newfound appreciation for the situation or the outcomes that may have come from the stress. We may not like every aspect of the outcomes, but we can focus on the positive aspects. (See Hardwiring Happiness.) The ability to reappraise trauma in more helpful ways that can be integrated into our autobiographical stories is a part of many trauma therapy programs. (See Healing Trauma and Traumatic Stress.)

Stress Vulnerability is Relational

John Bowlby started the idea that attachment to mothers could have long-ranging implications. Mary Ainsworth came up with the test – the “strange situation” – that allowed the attachment between a child and the parent to be assessed. Since then, the implications have been extended well into adulthood, particularly in the way that we relate to others as adults. (See Attachment in Adults and Attached.)

This matters, because the degree to which we felt safe and supported as a child, knowing our needs were going to be met when we expressed them, forms the bedrock of how we see the world. Is the world a fundamentally helpful and responsive place where our physical and emotional needs will be met? Or do we expect that the world will be indifferent or even punish us for our needs? These early formulations of how the world works are strangely sticky. There are some ways that we change our view of the world – particularly in a committed relationship – but not many.

This has a real impact on how we assess the stressors in our world. We can have a bias towards believing they’ll be harmful rather than helpful, and this bias will show up in the way that we experience stress. The less secure our attachment style, the more likely we are to perceive the world as a threat.

Vulnerability When Commitments Are Deep

There are really two phases of appraisal. The first is whether the stressor is positive, negative, or neutral – or a combination of them. If the stressor is positive or neutral, nothing happens. If it’s evaluated with the potential for negative impacts, a secondary evaluation of coping capacity is activated. The secondary evaluation is easier if the thing at risk isn’t that important. However, if a core belief is threatened, even if it means no material harm, our stress response will be high.

Buddhism believes that life is suffering because of attachment, and it seems that Lazarus and Folkman agree. (See The Seven Stone Path.) If you can remove attachment, then you won’t react with a stress response. To be clear, Buddhists aren’t speaking of the same attachment as Bowlby and Ainsworth. They’re talking about how we’re attached to outcomes and how we avoid or deny loss. We should believe in the power of others to help us meet our basic needs while avoiding becoming overly attached and dependent on other things.

It’s important to acknowledge that grief due to the loss of someone is a real and acceptable part of our experience as humans. (See Disenfranchised Grief.) The point here isn’t to say you shouldn’t be attached to people – attachment to people is good. The attachment to things is what’s bad.

Primitive Beliefs

We can’t completely avoid attachment to things or beliefs. Some of our beliefs, like the beliefs about the world expressed through Bowlby’s attachment, are so deeply wired into us that they’re hard to see. (See Attachment for more on Bowlby’s attachment.)

When we cannot see a belief, we cannot subject it to question. Until germ theory of diseases, we believed that sickness was caused by invisible forces or punishment by God. Without germ theory, there was no framework to challenge the beliefs. They were so embedded that there wasn’t an easy way for someone to see – and challenge – them.

Milton Rokeach in his 1968 book, Beliefs, Attitudes, and Values, explains that the more central a belief is to the entire belief system, the more resistant it is to change. It’s also more difficult to become aware of.

To Be Forewarned is to Be Forearmed

It’s a well-known idiom. From Lazarus and Folkman’s research, it’s true. People are better able to deploy coping strategies when they know there’s a problem coming. These coping strategies make the stressor less stressful. Even in times when there’s no way to prevent undesirable outcomes, coping strategies can mitigate their impacts.

Coping strategies and coping capacity have a huge impact on whether a stressor becomes stress. For some people, the stressor is normal and accepted. For others, it’s novel and threatening. Lazarus and Folkman’s model’s second stage is coping capacity – and it matters a great deal.

This means the more you communicate, the less stressful a change can be. (See Confident Change Management for more on change management.)

Reappraisal

It’s important to note that people will spontaneously reappraise situations, allowing them to transition from stress-free to stressful – or vice-versa. These spontaneous reappraisals are particularly relevant to long-term stressors, such as job or marriage turmoil. A small change can force a reappraisal and may generate a need to address the newly discovered stress.

Skillful leaders can trigger these reappraisals when conditions have changed sufficiently that the person may find the circumstances less stressful. Without a triggered reappraisal, they may be working from a sense of stress that’s no longer adaptive to the situation.

Attention Deployment

Coping strategies are, fundamentally, a way that we choose to deploy our attention, or cognitive resources, in an adaptive way. It’s a way for us to mitigate the perceived probability and impact of a stressor. The second appraisal is an opportunity to select and deploy coping strategies.

It’s important to note that not all strategies are adaptive. In the case of denial as a strategy, one can get caught in the loop of having to think about the problem to try to ignore the problem. (See White Bears and Other Unwanted Thoughts.)

Ambiguity and Uncertainty

There are two ways that people can fail to discover the meaning of a situation. Ambiguous situations lack the situational clarity that is necessary to signal the circumstances to most people. Along another pathway, a person may be uncertain, because they can’t properly interpret the meaning of the signals the environment is sending. Both cases lead to a lack of understanding, a failure to predict, and a failure to evaluate the degree of threat.

Some people intentionally defend themselves against a perceived threat by retaining or creating ambiguity in the situation. It’s a coping mechanism that allows them to avoid processing. While it may not be adaptive, it is still a coping mechanism. Even bad strategies are strategies.

Coping Devices

Coping devices allow us to cope with the anticipated stressor impact. Lazarus and Folkman organize coping devices starting with the most adaptive then going to less adaptive. The first order set includes self-control, humor, crying, swearing, sweeping, boasting, talking it out, thinking through, and working off energy.

The second order set includes withdrawal by dissociation, withdrawal by displacement of aggression, substitution of symbols and modalities for more frankly hostile discharge, and substitution of the self or a part of the self as an object of displaced aggression.

Third order devices include episodic, explosive outbursts of aggressive energy. These may be disorganized and include assaultive violence, convulsions, and panic attacks. The fourth order includes increasing disorganization; by the fifth, they propose a total disintegration of the ego.

George Vaillant, former director of the Harvard Grant Study, proposes four levels of defenses:

psychotic mechanisms, e.g., denial of external reality, distortion, and delusional projection
immature mechanisms, e.g., fantasy, projection, hypochondriasis, passive-aggressive behavior
neurotic mechanisms, e.g., intellectualization, repression, and reaction-formation
mature mechanisms, e.g., sublimation, altruism, suppression, anticipation, and humor

Viktor Frankl, in Man’s Search for Meaning, describes how people survived in the concentration camps by focusing on a very small segment of reality. The perception of the future was so negative that it wasn’t tolerable, so all that could be done was to focus on the moment and getting through it.

The Consequences of Coping

Every coping strategy has a short-term impact and a long-term impact. Some coping strategies are harder in the short term and easier in the long term and vice-versa. Consider how a learning coping strategy can be effortful in the short term, but it also increases coping capacity for future events. The coping strategy can reach a point of developing skills such that a stressor doesn’t register as stress anymore. Instead, it becomes the use of a skill to address a relatively non-threatening situation.

Conversely, some strategies like denial or avoidance allow the problems to increase in size and magnitude and therefore make them more difficult to deal with in the future.

When Coping Becomes Trauma

Lazarus and Folkman define coping as “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person.” This definition implies that we use coping strategies when regular strategies of response to a stressor aren’t sufficiently effective. The definition opens the door to the question about what point stress and coping temporarily overwhelm a person and therefore become trauma. (See Trauma and Recovery for this definition.)

Earlier I mentioned the differences between emotion- and problem- focused trauma. Lazarus Problem-focused coping is unlikely to become trauma because you feel as if you’re able to do something to make it better. Coping-focused trauma may be different.

Sometimes, the degree of stress and coping is major. Some sort of crisis requires you to engage with all you’ve got. If you meet the challenge, you may find resources you never knew you had. It may cause you to violate strongly-held beliefs, leading to a traumatic crisis of identity. And unfortunately, these cases can also break people to the point of needing help to put their lives and their self-image back together.

Stressful Events Are Cultural

As further evidence that emotions are evaluated, Lazarus and Folkman make a point that events themselves can be interpreted differently based on the culture. In one culture, an event could induce fear, it might elicit anger in a second culture, and it might be totally benign in a third. How we respond to an event (a potential stressor) is culturally conditioned. It’s based on the cultural norms and conditions.

Events are normal. It’s our appraisal of them – in the context of our capacities and environment – that make the difference.

Mismatch

Sometimes, the appraisal isn’t about the culture but more narrowly about the environment. In social work, the structure put forth is the Person-in-Environment system, which extends beyond the person to speak about their environment and the degree of match between the person and the environment. Mismatched skills and coping capacities to the demands of the environment can be stressful.

Conceptually, this makes a ton of sense. We are all unique and different with different gifts. There are going to be places that we don’t fit. Christina Maslach is famous for her insistence that burnout is the result of a mismatch between the person and their job. (See The Burnout Challenge.) I vehemently disagree, both because burnout isn’t constrained to vocational aspects but also because it misses the essential belief that burnout is a lack of feeling effective. (See Extinguish Burnout.)

Hassles

As mentioned in Demand, hassles matter. In that context, hassles matter to the people that will do the steps you want to engage with your product. But they’re also important to our health outcomes. Research on life events showed no impact on health outcomes – but daily hassles did. If a life is filled with hassles, then either there are a lot of irritating things happening to them – or they’re functioning poorly.

Taken together, if we want people to do more and to have better health outcomes, we need to pay attention to the degree of hassles in their environment.

Maybe if we can minimize hassles, we can improve Stress, Appraisal, and Coping.

Book Review-On Being Certain: Believing You Are Right Even When You’re Not

Robert Bogue August 18, 2025 No Comments

Before Galileo, everyone knew that the sun and planets orbited around Earth. They were certain of it, and the defense of this idea would lead to Galileo’s house arrest. On Being Certain: Believing You Are Right Even When You Are Not hopes to shake our certainty and to help us understand when the feeling of certainty doesn’t match our reason – or reality.

Malleable Memories

We often believe that the bedrock of our world is our memories. We believe that because we can remember it happened, it is a firm foundation that we can stand upon. However, as we dig deeper into understanding our memories, we realize that they’re not accurate reproductions of the past. In my review of Mistakes Were Made (but Not by Me), I recounted the fallibility of normal memory. In my review of Trauma and Memory, I drew a bright line between normal memories and traumatic memories. While traumatic memories are stuck in time, that still doesn’t mean that the way we experience them is true to fact. They’re not subject to the same distortions, but they are not necessarily a fair painting of the original picture, either.

In my review for Choice Theory, I wrote of Chris Argyris’ Ladder of Inference and how we select data that we focus on before further climbing the ladder. In short, even if we remember the picture, we don’t remember all of it.

This creates a problem about our certainty, because it means that we cannot trust even our own memories as reliable guides to what is and isn’t real. In a study following the Challenger disaster designed to better understand “flashbulb” memories, Ulric Neisser discovered that students would disavow their writings immediately following the incident. The exercise was to write the details of their experience in a journal. When he recalled the students 2.5 years later and asked them about their experiences at the time of the disaster, their perspectives had changed substantially, as would be predicted. However, when shown their own journals, they refused to believe the account they had written down. They could acknowledge the handwriting was theirs, but they couldn’t remember writing it, and they couldn’t accept what they had written was the accurate and unadulterated truth about what had happened.

Flying Planes

While I am still a licensed pilot, I rarely get to fly these days. During my training, there was a small amount of time devoted to what happens when a visual flight rules pilot suddenly and unexpectedly found themselves in instrument meteorological conditions. They explained that sometimes, if not often, when confronted with these conditions, your internal senses won’t be reliable guides. You may think that you’re banking left while you’re flying straight. More seriously, you may think that you’re going up when you’re straight and level.

I was taught that whatever the feeling you had, you should pay attention to the instruments. If two instruments said the same thing, then you had to trust the instruments rather than your feelings. It was only a few years before this that John F. Kennedy, Jr had crashed off of Martha’s Vineyard. The official report from the NTSB explained that Kennedy had fallen victim to special disorientation – the technical term for what happens when your senses or feelings deceive you – and had crashed the plane. The strategy for preventing the tragedy would have been to trust the instruments and let go of the feelings.

Instruments in a plane use multiple different systems designed to ensure that a single failure doesn’t result in a problem. When two instruments agree, you should trust that they’re right.

Cognitive Dissonance

Leon Festinger’s A Theory of Cognitive Dissonance describes how people resolve discrepancies. It is really about how we change our attitudes – or feelings. Cognitive dissonance is a conflict between what we believe and what we feel. As Robert Burton explains in this book, the odds are that the thoughts and memories we have will change rather than the feeling. The tendency to protect our existing beliefs causes the truth of the matter to get lost in translation.

There’s a deeper interaction between our sense of certainty and the tendency to resolve the dissonance by way of adjusting evidence. The less certain we are – either in disposition or in situation – the more likely we are to revise our attitude. The problem with being certain is when you’re wrong. The goal, then, is to make our attitudes more malleable in the face of opposing evidence – even if that’s a lofty goal.

Time, The Persistent Illusion

Many scientists describe time as an illusion. It’s a stubbornly persistent illusion. Instead of time having a constant linear function, we’ve seen that time is bent in places to accommodate the rule of gravity or the result of velocity. However, beyond the big picture time challenges, there’s also the challenge of our perception of time.

What we experience as being “in the moment” or being present may actually have to do more with leaning on previous experiences and our projections of the future. In my review of The Power of Habit, I lightly criticized Duhigg, because he changed some of the language from the research he was pulling from. More importantly, he incorrectly quoted the science that implied the temporal order of cue and reward. However, in doing so, he accidentally highlighted one of the challenges with our sense of time. The belief is that we experience time as it happens; in reality, the signals that we get from our senses aren’t perfectly timed.

Anyone who has experienced vertigo is aware of what happens when the delicate synchronization of inputs from our vestibular system, proprioception, and our visual and auditory clues are not synchronized by our brains. It’s the same thing that happens when we experience motion sickness. Our brains can’t synchronize the inputs, and the result is nauseating (literally).

In The Rise of Superman, Steven Kotler explains what’s possible when you extend the concept of what Anders Ericsson calls “purposeful practice” in Peak. The result is that people can achieve incredible feats that could best be described as super-human. It comes in part from the decoupling of conscious awareness from reaction. The mental models for the environment and reactions are so good that they can respond in milliseconds. What Gary Klein describes in Sources of Power with fire captains predicting how fires would work have been scaled down into moment-by-moment guidance.

In this environment, the sense of timing is fluid. It relies on seeing some of the future predictions as having happened, reviewing a bit of the immediate past – and the distant past that formed the model – to create a unified sense of time internally. That internal sense of time may actually be slightly ahead, with fairly accurate predictions filling in the missing pieces. We know from the work of David Eagleman in Incognito that our brains have no problem filling in the missing pieces once they’ve learned to do so.

This is important as we start to separate our thoughts from our feelings. In the moment we drop from a helicopter to ski down a mountain, where does the feeling of our competency meet the moment of our need for action? The problem of separating our thoughts and responses from our feelings becomes difficult when our predictions are intertwined with our feelings. We realize that our sense of time is more fluid than we might like to admit.

Science Approximations

The mass of an electron should be fixed. It is, in fact, fixed. However, it took science a series of steps to correct an error in Robert Millikan’s initial calculations of the mass of an electron to finally get to an answer. The Data Detective describes in detail how the error was introduced to the world of physics. Other measurements that largely disagreed with the value were discarded – until enough revisions had been made through small corrections to arrive at the correct value.

Science locked onto Robert Millikan’s value as the correct value because of his reputation. It took 60 years for the current (presumed correct) value to be generally accepted. Millikan’s error of about 0.6% was caused by another presumed-correct value for the viscosity of air.

Whether it’s fundamental theories like the theory of caloric that are disproven or simply small adjustments in what we believe we know, even our foundation of science isn’t as firm as we’d like to believe.

Catch-22: Pursuing the Thought

Jim Collins in Good to Great calls it the Stockdale Paradox. It’s the tension between having the faith to continue unwavering in your path and knowing when to make adjustments based on feedback. We don’t pursue a thought, because we already have evidence that it works. We only develop evidence that a thought is valuable after we’ve decided to explore it, to test it. So, while certainty can be a problem, it can also be an asset.

Mine Is the Reason

There’s a fallacy that we believe. We believe that, whatever our reasoning is, it is the right reasoning. Our way of viewing the problem is the only valid one. Despite awareness of wicked problems – which have no one right way of viewing them – we insist that our approach is right. In The Difference, Scott Page explains how we need people with different perspectives. Richard Hackman in Collaborative Intelligence agrees. James MacGregor Burns in Leadership shares how political leadership involves different perspectives.

Atheists Requiring God

When Richard Dawkins, perhaps the world’s best-known atheist, speaks of the privilege of doing what he does, who is granting the privilege? Does he really believe that there is no God or does his language belie a hidden truth he’s unwilling to expose? It could be that it’s nothing more than the turn of phrase that has us speaking of sunrises and sunsets when we’re aware that the Earth is rotating, and the sun isn’t literally gaining and losing altitude in the sky. Perhaps it’s the problem Daniel Wegner explains in White Bears and Other Unwanted Thoughts: to negate a thought, you must first think about the very thing that you don’t want to think about.

The thing I find most interesting about atheists is they’re convinced that those with religious beliefs cannot possibly be correct, and they’re absolutely certain there is no God. If they believed there might be a God, they’d be called agnostics instead. If the existence or non-existence of God is unprovable, because an entity like that would necessarily be beyond our current understanding, how can they keep On Being Certain?

Book Review-Beliefs, Attitudes, and Values: A Theory of Organization and Change

Robert Bogue August 11, 2025 No Comments

I jumped back in the wayback machine and headed to 1968, when Milton Rokeach released Beliefs, Attitudes, and Values: A Theory of Organization and Change. I jumped here, because I needed to learn more about primitive beliefs – beliefs that can’t be questioned. It was important to work backwards to find the work that framed our thinking around beliefs and what makes them malleable to change.

Understanding Beliefs

To understand primitive beliefs and why they’re not questioned, we must first start with a working definition for what a belief is. Rokeach explains, “beliefs are inferences made by an observer about underlying states of expectancy.” Said differently, it’s how we see the world and how we make predictions. (See The Righteous Mind and Mindreading for the importance of prediction.)

He believes seven, interrelated questions can help us understand someone’s beliefs:

What structural properties do all belief systems have in common, regardless of content?
In what structural ways do belief systems differ from one another?
How are they developed and learned?
What motivational functions do belief systems serve?
What is the relation between belief and emotion or, in other terms, between cognition and affection?
How do belief systems guide perceiving, thinking, remembering, learning, and acting?
What conditions facilitate or hinder the modification of belief systems?

Ultimately, Rokeach believes there are three kinds of beliefs:

Descriptive or existential beliefs (e.g. The sun rises in the East.)
Evaluative beliefs (e.g. This ice cream is good.)
Prescriptive or exhortatory beliefs (It is desirable that children obey their parents.)

Belief Resistance

Rokeach continues the exploration of beliefs by asserting that not all beliefs are equally important. The more central the belief, he suggests, the more it will resist change. Centrality for a belief refers to how many other beliefs are based on this one. Finally, he believes that the more central the belief, the more ripples that changing it can have.

Collectively, this means that while some beliefs may be quite malleable, others may stubbornly resist change. If you somehow manage to make them change, you risk substantially disorienting the individual as the ripples of the change spread across their perception of the world and themselves.

Five Classes of Beliefs

Rokeach believes in five classes of beliefs:

Type A: Primitive Beliefs, 100 percent Consensus – These are the kind of take-for-granted beliefs that led me to Rokeach. They’re the “‘basic truths’ about physical reality, social reality, and the nature of the self.”
Type B: Primitive Beliefs, Zero Consensus – “Beliefs that are not shared with others are therefore impervious to persuasion or argument by others.” Much like tacit knowledge, these can potentially be discussed using the right techniques. (See Lost Knowledge.)
Type C: Authority Beliefs – These are beliefs about who can be perceived as an authority. They are conceived of flowing from Type A beliefs.
Type D: Derived Beliefs – “Beliefs concerning matters of fact that are held solely because we trust an authoritative source…”
Type E: Inconsequential Beliefs – “they originate in direct experience with the object of belief and their maintenance does not necessarily require social consensus.” These beliefs are arbitrary matters of taste.

Rokeach clarifies that Type B beliefs can be subdivided into positive and negative types of belief owing to the degree that the belief is self-enhancing or self-deflating. He found that negative beliefs were more amenable to change than positive beliefs. Perhaps this is one factor in why it’s so difficult to change narcissist perceptions.

Disrupting Beliefs

Referring to earlier work, Rokeach explains that it was possible to move firmly held beliefs, but the direction of that change wasn’t controllable. Three schizophrenic patients, each believing they were Jesus Christ, were placed in the same unit. Being confronted with others who firmly believed they were who the others believed themselves to be placed a strain on the psychological systems. That strain caused changes in inconsistent and unpredictable ways.

This is a cautionary tale for those who want to make changes to beliefs in a specific direction. There’s no guarantee that the direction of the change will be the one that’s desired – it can quite easily go in the opposite direction.

Race Relations

Given the civil rights focus at the time of its writing, it’s not particularly surprising that this book addresses race relations. A series of experiments was designed to isolate whether belief systems agreeing or conflicting was more or less important than race when making a decision about who to go to lunch with and who to work with. The study was conducted at Michigan University and found that belief alignment was 30x as strong as ethnicity in terms of determining who someone would engage with.

Consistent with other works, Rokeach concludes that ethnicity mattered when you knew nothing else about a person, but as soon as you knew them enough to know their values, your focus on decision making shifts to their values rather than stereotypes about their ethnicity. (See also Mistakes Were Made (But Not by Me).)

Rokeach does acknowledge that his studies were done in a state with little race controversy. Attempts to replicate the study in a southern university were thwarted by security concerns for those who would be involved with the study.

Values

Rokeach defines two kinds of values:

Instrumental Values – Values about conduct like honesty and courage
Terminal Values – Preferred end states like security, happiness, freedom, and salvation.

These values are activated inside of an attitude and may have a profound impact on behavior. Like Haidt’s foundations of morality (see The Righteous Mind) and Reiss’ motivators (see Who Am I? and The Normal Personality), values can be in conflict. The “winning” value has a dominant impact on both attitudes and behaviors.

Attitudes

Attitudes are conceptualized as a composite organization of beliefs and values. Solomon Asch wrote, “Attitudes are particularly enduring sets formed by past experiences.” Others agree that attitudes are developed through the principles of learning without specifying what the learning process is. They do, however, point out that we’re wired to develop beliefs rather than facts. This is consistent with the idea that we’re prediction making machines rather than fact tabulating computers.

Attitudes are organized beliefs that have three components: cognitive, affective, and behavioral. In other words, they impact our thoughts, feelings, or behavior. Attitudes can therefore take on a capacity for being for or against something in ways that beliefs cannot. We can be pro- or anti- any topic. However, when consensus rises to approximately 100%, we rarely speak of pro- and anti- attitudes, because the there is no controversy for us to attach our attitude towards.

Total Cognitive System

Our beliefs, values, and attitudes are connected together into a total cognitive system that we use to live our lives. This system is augmented by our opinions, faith, and desires. If we want to understand and predict how others will act, we need to explore their Beliefs, Attitudes, and Values.

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