Things that Get in the Way of Interpersonal Effectiveness

As you more than likely know, Interpersonal Effectiveness is one of the four areas targeted in DBT skills training (along with Mindfulness, Emotion Regulation, and Distress Tolerance). It's also the only skill set that goes into detail about the various factors that interfere with effectiveness. When considering teaching interpersonal skills to clients, I think it can be especially useful to think about what is currently getting in the way for them.

Linehan identifies five categories of factors that reduce interpersonal effectiveness:

1) Lack of skill - the person just genuinely doesn't know what to say or how to act to achieve their goals in a given interaction

2) Worry thoughts - the person has the skills to interact effectively, but worry thoughts keep them from doing or saying what they want. Worry thoughts call into three main categories: worry about negative consequences (they won't like me, they'll think I'm crazy), worry about whether the person deserves the desired outcome (they shouldn't like me, I don't deserve a raise), and worries about not being effective (they aren't going to listen to me, I'm going to fall apart). Some of these thoughts may involve calling oneself names (stupid, crazy)

3) Emotions - in and of themselves, intense emotions may get in the way of the person's ability to act effectively. The person says and does things based on emotion rather than skill or goal.

4) Indecision - the person can't decide what to do, or what they want in an interaction. They may be ambivalent about addressing something, or may be unable to figure out what the right balance is between asking for too much vs not asking for anything, and/or between saying no to everything vs agreeing with everything.

5) Environment - sometimes skillful behavior still doesn't achieve the desired result, simply because of the environment. For example, other people may hold too much power, other people may be threatened by effectiveness, or may threaten punishment, or may not give in without requiring the person to sacrifice self-respect in some way.

Figuring out what is keeping someone from behaving effectively is important because different interventions may be warranted. If someone simply lacks skills, skills training is an obvious answer. If worry thoughts are getting in the way, cognitive restructuring and thought stopping may help. If emotions are interfering, calming and distress tolerance skills should be used before trying interpersonal effectiveness. In cases of indecision, a decisional balance may help to weigh pros/cons. Finally, if the environment is the problem, people may be coached to consider how to navigate the expected responses, adjust their expectations (perhaps with radical acceptance), and develop an exit strategy.

Are there other things that keep people from interacting effectively with others? How do you address it?

To Avoid an Identity Complex, Develop a Complex Identity

Last week, I wrote about the role of identity in athlete suicide - more specifically, how the athlete role can be come central to someone's identity, making it devastating when they are unable to continue in that role, as a result of injury, age, or whatever. Since writing that post, I've learned more about how a similar phenomenon may apply to other demographic groups. It all seems to boil down to self-evaluation.

Self-evaluation is something that we all do, practically without thinking: we evaluate ourselves based on how we're doing in various aspects of our lives that are important to us. Not just important, but important to how we see ourselves. How we define ourselves. Who we think we are in the world. When we're doing well in areas of our lives that matter to our self-image, we feel pretty good. When we're not doing well in these areas, we feel bad.

Now, nobody's perfect, and life tends to have ups and downs. Consequently, we're all liable to have times when we're not living up to our own standards in one area or another. How much these times affect us depends largely on whether we have a variety of areas contributing to our self-evaluation...or whether we only have a few. In other words, it depends on the complexity of our identity.

Take the star athlete, for example, who has been playing his or her sport since childhood, often setting aside other life domains to focus on athletics. Athletic performance - good or bad - is likely to have a significant effect on that person's mood and self-esteem. And, when athletics are no longer possible, there is nothing to fall back on to maintain a stable sense of identity and worth.

Athletics is an easy example, but it's not the only example. Plenty of people put "all of their eggs in one basket," as it were. Veterans often develop a military identity that makes it hard to transition to civilian life (after all, basic training is designed to create this kind of identity!). In eating disorders, people's self-evaluation is largely based on shape, weight, and appearance. Musicians, actors, models, politicians...many narrow their self-evaluative lens to a very limited number of areas. And while the risk of doing so obviously varies between these different groups, it's always risky.

It is far healthier and more satisfying to develop an identity and system of self-evaluation that considers a variety of different life domains: work, relationships, hobbies, interests, etc. If we have several important areas - even if they differ in level of importance, as obviously they will - our self-image is protected from the inevitable low points in any given area. Work isn't going that well, but you have a great family. Or there is conflict at home, but your tennis game has never been better. Whatever the specifics, having multiple "baskets" for your eggs means that you maintain a relatively stable sense of self-worth.

The bottom line: having several areas of life that feel important and contribute to your self-image not only enriches and expands your life, it also preserves your sense of yourself and your worth through life's ups and downs. In other words, to avoid an identity complex...develop a complex identity!

The Mental Filter

Our brains really are amazing tools. They take in and synthesize incredible amounts of information, coming at them from every direction, all of the time. Think about just the sensory information - we are surrounded by sounds, visual stimuli, texture, taste, smell, temperature, movement around us.... Then, on top of that, we have memories, interpretations, concepts, goals, values, to-do lists, relationships...and innumerable other things.

If we registered all of this information, we'd constantly be on mental overload. Again, think about sensory information. Have you ever had the experience of entering a room and noticing a bad smell, but then after a little while not being able to smell it anymore? When sensory information isn't changing, our brain decides that we don't really need continued awareness of it, and begins to filter it out. That's why they make those air fresheners called "noticeables," which alternate between two scents so that you can still smell them!

We don't have to think about filtering out information in this way - our brain just does it. That's usually good (since the point is to lessen our sense of mental overload), but it's also kind of scary: your brain is deciding what information to give you, and what not to give you, without your conscious participation. If it can filter out one of your five senses, what else is it filtering out?

Quite a lot, as it turns out. In fact, the mental filter is one of the more problematic cognitive distortions. The cliche "you see what you want to see" is actually not far off. It may be more accurate to say "you see what you expect to see." What happens is that our brains register our expectations, and then, as they're screening incoming information, screen in information consistent with our expectations, and screen out contradictory information. If your expectations are realistic, this is useful; however, if they are distorted (for example, by a belief in your own lack of worth, or the world being out to get you), competing information would be helpful.

Unfortunately, the brain is more geared to problem solving than anything else, so it tends to look for potential problems. Therefore negative information seems more likely to be screened in than positive information - further contributing to pessimistic expectations, assumptions, and behavior. Denial may be an exception - when it would be too painful to acknowledge something, our brains screen out confirming evidence, often resulting in a more positive view than is warranted. The end result is the same, however: behavior that does not take the complete picture into account, and therefore may not be fully adaptive to reality.

How else do you see the mental filter operating?

Hazing Is Not Child's Play

There has been a lot of news coverage lately on hazing, as a result of deaths and subsequent arrests on multiple college campuses around the country. Some high-profile recent hazing charges have included a fraternity hazing death at Cornell, and a marching band hazing death at Florida A&M, both in 2011. There has been a growing push (among adults) for more significant, and more effective, efforts to end hazing, which has long-since been "banned," without a notable reduction in hazing behavior.

In order to make any significant changes in hazing, I think we have to begin by asking  how and why it occurs. Hazing is ostensibly a form of initiation - a way of inculcating the group identity into new members. It is most often associated with fraternities, sororities, athletic teams, and marching bands. However, it may be most commonly performed with military recruits (I know I'm making a controversial claim, here, but what else can we call boot camp, where recruits are subject to physical and mental assault to "break them down?").

That explains the why. What about the how? How do normal kids, with sound moral character and prosocial behavior in most areas of their lives, end up hurting each other in the name of group cohesion? We know that social groups can develop "groupthink" - groups already composed of people with some similarity develop shared faulty reasoning that evolves from pressure for uniformity, and suppression of contradictory opinions. Groups also tend to make riskier choices than individuals, and normal individuals have been induced to behave violently toward others as a result of obedience to authority (as in the Milgram experiment), and as a result of social role and distinction between social groups (as in the Stanford Prison Study).

Other factors that may contribute to willingness to participate in hazing parallel domestic violence. Those who have experienced hazing as part of their own initiation into the group may "identify with the aggressor" - in this case, that means adopting the group identity, and ultimately wanting to be like the people who haze them. They may also harbor some anger, however, and express it through the hazing of the next generation of group initiates, perpetuating the "cycle of violence."

So, knowing that group membership is an important source of identity and esteem for humans in general, and that rites of passage may be particularly meaningful during the transition to adulthood, it behooves us to find other ways for young adults to establish group identities and mark transitions without harming each other. Planned team-building activities provide one avenue, but have not proven sufficient to stop hazing.

Changing the mentality of the whole group is a bigger challenge. The only way I can think of to approach it that has the slimmest chance of working is having adults involved with each group facilitate ongoing, frequent discussion of how the group wants to identify itself, its norms and culture, and its traditions, including initiation. The whole group needs to get to a point of endorsing a violence-free process.

It would go a long way toward this end if we as a culture also work to end institutionalized and sanctioned forms of hazing, such as those employed by the military. We need to shift our collective understanding of group identity to preclude and prevent violence.

For more information, see Cornell's hazing website.

Useful Mnemonics on Suicidality

Continuing my series on suicide, the training I had this week also made me remember a few very useful things I learned in social work school about suicide. Both have handy mnemonics (hence this post's title).

First, for assessing suicidality, remember SLAP:

S - Suicidal ideation

L - Lethality

A - Accessibility

P - Plan

Unfortunately, they couldn't put it in the actual sequence of assessment (well I supposed they could, but "slap" sounds better than "spla" (or God forbid, "splat"). Basically, when it comes to suicide, you first want to know if they have thoughts about it (and no, asking if someone is thinking about suicide does NOT plan the idea - they've done plenty of research to disprove this myth!) - Suicidal ideation. If they do have thoughts, you want to know if they have a Plan. If they have a plan, you want to know if the means are Accessible, and how readily (something that's in the house? something they know where to buy?). Then you want to consider its Lethality (i.e., likeliness they could survive if they act on it). 

However, it's probably more important to consider intent - not part of the acronym, but for my money, more crucial than lethality. After all, if someone has a lethal plan they'd never act on, they are at less risk than someone with an ostensibly less lethal plan they have every intention to act on. Plenty of people die by "less" lethal means, sometimes even when they only intended the act as a so-called "cry for help." It's Russian roulette. 

The second mnemonic has to do with people's motivation for attempting/committing suicide. These factors help us recognize serious suicidality, and better understand our suicidal clients. They are the 3 R's:

Relief

Rebirth/Reunification

Revenge

Relief is perhaps the most obvious. People who think about suicide are typically in pain - mental, physical, or both. They may have lost hope of ever feeling better while living, so they begin to consider whether they might be "better off dead." Even people who think there is no form of existence after death may think that at least their pain will end. If it starts to seem worth it - that's a big sign of risk.

Many people do believe in some form of existence after death, however. Therefore, they may not only think their current pain will end, but also think that they will get a better life instead - i.e., Rebirth. That includes both reincarnation (rebirth into a body on this earth), and "rebirth" as transition into some other form of existence (e.g., heaven). An idealized image of a better life can be a powerful motivation for suicide. Even more powerful, perhaps, can be an image of Reunification - getting to see and be with loved ones, both people and pets, that have died. This motivation is a major reason why recent loss is a risk factor for suicide.

Finally, sometimes the motivation for suicide can be less about oneself, and more about someone else. Sometimes people develop a fantasy about how other people will feel and react if they die, most notably loved ones. Suicide can seem like the ultimate way of getting the "last laugh" - causing pain without the possibility of retaliation. 

While none of these things are...pleasant...to think about, they are all important, because most of us work with clients who already have risk factors for suicide. What other things do you keep in mind when you think about suicidality? 

Desperate?

I live in a coastal city. To get to and from...well, just about anywhere...I have to go over a major bridge. Sitting in rush hour traffic, there is plenty of time to notice all the billboards and signs. And although I've driven over the bridge countless times, I am always struck by one sign in particular.

I suppose it's four signs, actually: one on each side of both the Northbound and the Southbound levels (one is above the other). The signs read "Desperate? Depressed? Call the Samaritans" (a suicide prevention organization and "helpline"). 

Usually, when I notice these signs, I shudder and look away. Working with potentially suicidal clients, I don't like to think in too much detail about possible scenarios - especially what I've been told about this particular bridge. However, I appreciate the fact that it would be impossible to make it onto the bridge without seeing one of these signs - at least everyone who considers this path is offered one last chance to reconsider.

I imagine there are some people on the verge of suicide who do give the world one last chance to support them. I suspect that these people are the ones who are ambivalent about death - who may not see it as a positive thing, but may not see another way out. These may be the same people that hint to other people, or even seek treatment, when they are considering suicide. However, as I was reminded in a training today, ambivalence and desperation are not always present immediately prior to suicide (for example, when someone is approaching the bridge). Instead, having made the decision to commit suicide, many people experience relief and become more cheerful. The desperation has already ended.

When I worked with my first chronically suicidal client in outpatient therapy, my supervisor provided me with some of the best advice I've gotten on this subject. He acknowledged what I already knew - that this client ticked all the boxes for high suicide risk - while also reassuring me that I couldn't take on the responsibility of "saving" him. His life, or death, was in his hands, not mine. I could make sure that he knew help was available, and how to access it. I could work with him to build motivation to live. And I could assess frequently for risk and need of hospitalization. But I couldn't take on the sole responsibility of keeping him alive.

The second part of his advice dealt with how to assess someone who was suicidal at baseline. Given that he always had thoughts of suicide, and had a standing (lethal) plan, but denied intent, and had already been hospitalized and releases, what would tip me off if he became more acutely suicidal? A marked brightening of affect. Increased energy, improved mood, enthusiasm. Lightness.

I couldn't look for depression or desperation, which were always present. Instead, the real risk would come when and if he suddenly seemed to improve. This could be a dangerous sign that he had found a "solution" to his problems, and was feeling relief because everyone would soon be over.

Fortunately, I never had to experience that eerie mental status change with him. However, my agency's current risk assessment policies were developed after a suicide on the inpatient unit, presaged by sudden improvement in mood and program compliance. The take-home message: beware of sudden improvement in risky clients! 

How do you assess for suicide, particularly in high-risk clients? 

The Role of Identity in Athlete Suicide

Following the suicide of long-time NFL great Junior Seau earlier this month, news media focused on the question of whether playing football - or, more specifically, suffering concussions - could involve brain trauma that might ultimately lead to clinical depression, and even suicide.

However, an alternate possibility discussed on WBUR's Radio Boston today seems more compelling to me. The program asked: what happens when athletes can no longer participate in their sport, for whatever reason? After all, the athlete role can take on immense personal significance, becoming a pivotal part of a person's identity. When injury, health, other obligations, or retirement in the case of professional athletes, removes the person from the athlete role, it is often experienced as a significant loss - not only of an enjoyed activity, or a social network, but of one's identity.

Many people experience such a loss in youth. A large percentage of kids play sports in high school. Many will experience an injury that sidelines them, temporarily or permanently, and these kids - who are in the process of defining themselves anyway - struggle with who they are without their sport(s). Beyond this number, the majority of high school athletes won't go on to play at the college level, and the majority of college athletes won't go on to play at the professional, national or world levels. At some point in young adulthood, the vast majority have to grieve the loss of their athlete identity, and find a way to define themselves separate from sport. Fortunately, young adulthood is a time for developing our identities, and this loss, while devastating, does not usually push people to the point of suicide - identity is still developing, and therefore, alternate identities are available.

We can only imagine that, for those exceptional few who do go on to more advanced levels, instead of developing an alternate identity - an understanding of who they are separate from sport - the athlete identity crystallizes into their core sense of self. Unfortunately, the human body does not continue to perform at an elite level indefinitely - at some point, every athlete reaches the point where they can no longer be competitive at the same level.

Of course, some will find ways to continue their involvement in sports - they play in recreational leagues, become coaches or commentators. However, I imagine the loss would be more profound the more advanced people go in their athletic careers. For example, a football start like Junior would lose not only a central part of his identity, but also the social roles of teammate, role model, and celebrity, not to mention the income and lifestyle. If you've spent 20 years in the NFL, and college, high school, and perhaps middle school teams before that - if you're in your 40s and have known no other life - what does it feel like to retire from football? An immense void, I suspect. Some are able to redefine themselves, while others are not. Suicide is an extreme response to the latter eventuality.

That raises the question of how loss of identity or role may factor into suicide more generally. We know that older adults are at greater risk for suicide, and loss of role, functioning, and/or identity is likely a key reason. What about other groups? How do you understand identity issues in depression and suicide?