The Adaptive Role of Anger: Anger Has a Voice in Military Service and Suicide Risk

John was a Navy Seal who had seen more than his fair share of war. He saw and did things that I’ll spare my readers – not to protect John, but (just as he would want) to protect my readers from even imagining things human beings aren’t meant to see. One day in session, he was cataloguing various things that recently had him agitated: the politics in his unit (that only seem to disappear when in the immediate throes of war), his ex-wife seemingly trying to turn his daughters against him, and his home remodeling contractors stealing meat out of his freezer.

When John talked about the politics in his unit, he seemed despondent – sad and indignant – that brothers and sisters in arms could so easily get caught up in seemingly trivial matters when back home in the United States – that they could turn on each other. In fact, John had just been given minor disciplinary action for being “disrespectful” to a higher-ranking officer. John spoke about the differences between being a military member downrange (when all that mattered was life and limb) and being a military member stateside (where everyone was presumably safe). John said it’s simpler downrange, because the rules are easier and intuitive: Don’t get killed. Don’t let your allies get killed. Downrange, no one has time to worry about who did or didn’t say ‘hello’ to them that morning in an appropriately enthusiastic fashion. When life is for all intents and purposes ‘safe,’ the rules become more complicated. In safety, people have the luxury of behaving badly.

John was equally despondent when he talked about his daughters. They were now old enough to assert to the courts whether or not they wanted to go on visitations with him, and he was convinced that their mother was brainwashing them to hate him. He didn’t want to put his daughters in the middle of things, so he felt unable to fight back. He was scared of not seeing them. He was hurt by their distance. He felt powerless to do anything about it, and the pain was bigger than he could put words to.

But when John talked about the contractors stealing meat from his freezer, he was enraged – incensed! He was furious that they would violate his personal space by taking from him, and he verbalized thoughts of violence in response to them casually taking his hard-earned money. He railed about his stolen meat for at least 20 solid minutes. I watched as his face turned red and veins bulged in his neck.

When he finally exhausted himself and fell quiet, I briefly remained quiet too. Then I pointed out to him that, despite the gravity of his career being threatened by disciplinary action and despite the gravity of his relationship with his daughters being threatened, he exuded the most anger about his stolen meat. He sat back, and a look of surprise crossed his face. “You’re right, doc. I think that after dealing with everything else, I just can’t handle one more thing.

He was partially right. The stress he carried around on his shoulders did indeed give him less patience for the routine stressors (stolen meat or otherwise) of life. His stress was leaking out everywhere. But there was more to it than exacerbation.

John was a moralistic man. He believed in doing what he believed was right, and he believed in exercising uncompromised integrity in following his moral compass. Despite lifelong hardship, he stayed the course…refusing to allow the hardships of the world steer him away from what he believed was right.

John was raised on trauma – an alcoholic, abusive father and submissive, victimized mother. He went to war – witnessing, exacting, and touching human death and suffering. He survived a toxic marriage – an unfaithful and verbally abusive wife who used the children to control him. Yet he persisted – white knuckling through with a tiny belief that there was order in the world and good, moralled people whom he just hadn’t met yet. He couldn’t survive without these beliefs, as his beliefs were the very thing that gave him a breath of hope and a reason to keep trying.

When his career was threatened (after everything he sacrificed) and when his daughters seemed to be turning against him, he couldn’t fully compute this information and the overwhelming landslide of feelings behind it. His brain wouldn’t let him…because it threatened his very reason for continuing to live. His brain protected him from the gravity of these events, and he froze in response.

The theft of the meat, on the other hand, was safe to feel. It was safe because petty theft isn’t super high on the hierarchy of bad human behavior. Petty theft sucks. It doesn’t feel good, and it’s mighty inconvenient. But it’s not murder, kidnapping, or any of the higher order wrongdoings that John’s survival couldn’t handle. His brain could let him feel petty theft, because petty theft didn’t squarely make him ask himself, “What’s the point of living?

And so he raged and railed against it…indignant and dripping with disgust.

Had John acted out his rage on the sticky-fingered contractors, the news headline would’ve read something like this: Local military member bludgeons contractors for stealing rump roasts from his freezer. And just like that, he would’ve disappeared into cultural stereotypes as another unhinged troop.

On the societal level, we say that veteran suicides are important to us. We donate to veteran causes. We thank people for their service. We make puppy-dog faces when we hear that one of our troops or veterans are suffering after war. We spend millions on social media blasts and campaigns designed to educate the end-user about risks and warning signs. But does any of this really work? And how are we proving that it works? Or is it possible that we’re just hemorrhaging time and money on suicide prevention tactics that are ineffectual and only actually serve to make us feel like we’re doing something?

Is anyone meaningfully asking service members or veterans what they think of the PSAs and programs we spend millions for?

Who do you picture when you think of a veteran who’s at risk for suicide? If you picture the sad, mopey Eeyore, you might be wrong. And being wrong in this equation can be fatal.

While the at-risk veterans who demonstrate Eeyore-like behaviors do exist, at-risk veterans are just as often the angry, irrational, short-tempered hot-heads that inadvertently (or advertently, as it were) push people away through their aggressive behaviors. They’re the guy at work who punches a wall in response to the slightest inconvenience. They’re the woman that’s stoic and repels her coworkers’ attempts to befriend her. They’re the guy who gets in the face of the person who stole their parking space in a store parking lot. They’re the woman that a boss evaluates as “defiant and difficult to correct.” They’re the guy that bludgeons contractors over meat.

At-risk veterans and service members are often over-flowing with bitterness, frustration, and emotions that they don’t know how to manage, and these emotions are most safely converted to anger, as anger can feel safe. Anger doesn’t make a trauma survivor feel vulnerable, which is critical. I have yet to meet at at-risk veteran or service member who wasn’t repulsed at the idea of feeling vulnerable. They’ve had more than their fair share of feeling vulnerable, and in their life experience, vulnerability leads to death and mayhem. Vulnerability must be avoided at all costs. So anger is safer. Anger is the emotional and behavioral equivalent of standing tall and waving your arms to ward off a mountain lion. Even if you feel like a small and fleshy snack, your survival is optimized by making yourself appear big and bold. It’s the human way of showing that – even if you’re going to lose in the end – you’re not going down without a fight. And isn’t that central in the Warrior Ethos? “…I will never accept defeat, I will never quit…”

While I was still in the uniform, I tried to shift the suicide prevention message such that people would take a second look at their angry counterparts (e.g., https://www.kirtland.af.mil/News/Article-Display/Article/817278/tap-into-your-empathy-says-suicide-prevention-program-manager/). Alas, that message always seemed to get buried under a pile of the status quo.

As long as we ignore and reject this message, we aren’t truly moving towards changing our country’s devastating veteran suicide problem. And by not doing that, we’re failing at adequately caring for the people who sacrifice their lives for our way of life.

In clinical work, it’s exceptionally rare that I meet an at-risk veteran or service member who hasn’t had or doesn’t have “anger problems.” One patient in particular comes to mind; we’ll call him Fred. (Yes, I intentionally use blasé fake names.) When Fred first came to the military mental health clinic, he told the mental health technician that he was there because of “anger.” Fred also noted that he had a PTSD diagnosis from a different facility, but that he wasn’t willing to have that be the focus of treatment, as he had “been there, done that.” He was emphatic that he was unwilling to do “worksheets and repetition therapy,” because they didn’t work. So the technician asked me to take Fred (even though I was over-capacity and wasn’t supposed to be taking new patients).

Fred was a piece of work. He reported that both his commander and wife had incessantly complained about his temper and attitude, but he didn’t think he had a problem. “I’m just here to appease them. The real problem, if you ask me, is that people don’t like to hear the truth, and I’m not willing to change what I say just because it might hurt their feelings.” Fred and I arm-wrestled every time he came in. Sometimes, I’d win the match by the end of the session, and I’d get all naively hopeful that we had hit a pivot point. But then he’d come back next time – all yoked up and ready to wrestle again. The struggle was real. He was a pain in my ass…and I told him that. (Not gonna lie: I think his amusement at irritating me was part of what kept him coming back.)

Somewhere along the way, I completed my contract, separated from service, and opened my private practice in the network. Fred was allowed to continue work with me here. One day, I received a random email from his wife thanking me for helping him so much. She said he was like a different man. Fred arrived for his next session – yoked up and ready to wrestle – and I told him that his wife outed him. “What the hell?!” I asked him. “You never told me that things were changing out there.” He smirked and then confirmed that he had been getting positive feedback (both at home and work) about his improved demeanor and functioning. And then we finally hit a pivot point…

Some sessions later, Fred admitted to me that he had once had a gun in his mouth. He told me about years on end where he struggled to keep going and often believed he couldn’t tolerate the pain he carried daily. At his own pace, he started talking to me about where he had been, what he had seen, and who he had lost. (Even Fred will tell you that he still wrestles me sometimes, but maybe that’s just when he needs to get out some safe anger and bitterness to cope with his world.)

To adequately serve and help our service members and veterans – and prevent their untimely demise – we (as a profession and a populace) need to learn to see and orient to their anger in a different way. We need to learn that their anger is hard-learned, that it serves a purpose, and that (in the context of their experiences) it’s adaptive. Only then will we have any creditability with them or will they feel seen. That’s step one.

And then we need to help them strategically and adaptively turn down the volume on their anger, but that’s a different topic for a different day…

Joye L. Henrie, PhD

 March 2019

(Photo credit: Military OneSource https://public.militaryonesource.mil/health-and-wellness/managing-stress?content_id=282360)

Winning without Power Poses: 10 Keys to Success for Commoners

In June 2018, I returned to Arkansas National Guard Youth ChalleNGe (my alma mater), where I gave the keynote speech for their 25th Anniversary celebration. The director and coordinators were gracious enough to give me complete artistic liberty in my talk. I took full advantage of this latitude and gave a talk on why I hate success stories. (I’m sure there were some folks briefly holding their breath in the audience.)

Long story short, I hate the typical depiction of success stories, because they only emphasize the shiny outcome. The path from point A to point Z seems mystical, which disallows aspiring young people from seeing the gritty core of the journey.

After conveying this message, as well as a brief summary of the highs and lows of my own journey, I shared with the audience the ten “keys” that were vital to my success. Unfortunately, what you will find here isn’t a quick fix or a magic pill. It’s a list of hard-learned and hard-earned lessons that require endurance, intestinal fortitude, and integrity. If that’s a list you can get behind, read on.

1. Define success

I’ve encountered countless people over the years that say they want to be successful, but if they are asked more questions about what that is or what their life will look like, they tend to give vague answers. We all know that if we want to take a road trip to an Airbnb we reserved, we have to know where the Airbnb is. How else would we get there? Similarly, to achieve our desired “success,” we have to define what that looks like. Is it a degree? A profession? A level of contentment? A specific dollar amount in savings? In order to arrive at our destination, we have to know what our destination is and plan out the best route to get there.

Arguably, it’s just as important to define success so that we know when we’ve reached it. (How will you know you’ve arrived at if you don’t know where you’re going?) If success is a nebulous thing in our heads, we may find ourselves mindlessly and perpetually trying to reach up and grab that next golden ticket – deeming ourselves only as successful as the content of our last day. That’s a problem, folks, because a lot of days are anything but flashy. And, if we are always striving for the next thing, we will never enjoy the contentment and ease waiting to be derived from the fruits of our labors.

2. Volunteer

Even when I was lost and confused…and when I didn’t have two pennies to rub together, I volunteered. In the beginning, I couldn’t have told you why, but in retrospect, I recognize that I needed to believe that – irrespective of my situation or history – I had something to offer. I needed to connect with other humans in a non-superficial way. I needed to be a part of the world and to be inspired by others who were fighting their own battles and courageously living all the gory details of their own lives. I needed to be around others who aspired to improve the world – not just take from it. I needed perspective, and I needed to be grounded and humbled. Having these needs met became intoxicating (to the point that I eventually needed to detox a bit…but I already addressed that in my self-worth blog).

Volunteering in nursing homes as a teenager and as a long-term care ombudsman as a young adult taught me that we could either live a life of joy or a life of regret. Either way, we all meet our eventual demise. Joining Civil Air Patrol and volunteering for search and rescue taught me that in our most agonizing moments of crisis, we are all relieved when we see another human being – irrespective of their race, gender, religion, nationality, etc. Civil Air Patrol also taught me the value of specificity, the pride of a job well done, and the nobility of pushing myself when I felt I had nothing left. Opening a donation center for foster youth reminded me daily that all children just want to be children. They want to feel normal when everything around them is abnormal. The donation center also taught me that everywhere there are needs awaiting a warm body to step up and meet the need. Volunteering for the booster club taught me that nearly any problem could be solved with comradery and communication. And volunteering for the HOA taught me that everywhere there are hurt people hurting people, but there are just as many people who want to buffer the pains and blows of the world.

In every day, there are lessons to be learned and joys to be had. By giving back and engaging, we’re empowered to change a little section of the world…and we’re reminded to be humble.

3. Be stubborn

When I was in my thirties, I remember my exasperated dad saying, “You are the most stubborn person I’ve ever met!” Without skipping a beat, I responded, “Where do you think I got it from? You’re the most stubborn person I’ve ever met!”

While unbridled and ill-structured stubbornness can get us in trouble and stymie our journeys, well-vectored stubbornness can get us where we’re going.

In order to be successful, I have had to stubbornly pursue my desired outcomes (i.e., becoming a clinical psychologist, developing and maintaining a high-quality marriage, breaking generational cycles, securing debt freedom, etc.) – even in the face of vocal doubters. I’ve had to stubbornly believe that it was possible to avoid becoming a statistic – even if I had never personally known anyone that achieved this. I’ve had to stubbornly withstand pressures that would compromise my integrity, and I’ve had to be willing and able to stand tall…even when that meant standing alone.

Standing alone or feeling alone can test the will of any human, but if we remember where we’re going, why we want to get there, and who we want to be, standing alone can be tolerable. (Optimally, however, part of our stubbornness should be carefully and deliberately selecting the right people to stand around us.)

4. Read Sun Tzu

The first time I was exposed to The Art of War by Sun Tzu, I interpreted it at its face value: war strategy. Fast forward a handful of years, and I randomly came across a Sun Tzu quote while trying to survive a toxic work environment: “If ignorant both of your enemy and yourself, you are certain to be in peril.” Suddenly, I saw The Art of War in a new light. I went back and skimmed the Cliff’s Notes version, and what I found was a whole new world…a world where Sun Tzu was now talking about how to manage difficult relationships and difficult people. I read it with an eye on how to navigate the choppy waters of working for an ego-fragile manager: “…encourage his arrogance…The supreme art of war is to subdue the enemy without fighting.”

Sun Tzu told me not to show my cards unnecessarily: “Be extremely subtle, even to the point of formlessness. Be extremely mysterious, even to the point of soundlessness. Thereby you can be the director of the opponent’s fate.” From this, I extrapolated the thought that if a toxic boss keeps me guessing, why wouldn’t I keep him guessing? I only give him more tools to abuse me if I’m operating in the dark while he has a flood light. Now obviously I’m not suggesting that anyone break company policy or fail to adhere to their job standards. I’m talking about personal shortcomings, fears, and emotions. Why give an abusive boss that power over you?

And speaking of power over you, in situations of abusive power imbalances, we’re prone to getting stuck in cycles of reactivity, and our captors capitalize on this. Staying healthy requires us to get unstuck, recognize unnecessary fights, and remain nonreactive: “He will win who knows when to fight and when not to fight.”

5. Sulk only briefly

A patient of mine once came to her follow-up session and made a confession: In a bout of sadness, she had eaten five tacos the night before. She was ashamed and self-loathing over her five tacos. “So what?” I asked her. She had been so caught in a whirlwind of shame and “shoulds” in her mind that she overestimated the importance of her five sad tacos, and my “So what?” caught her by surprise.

Here’s the deal: Life can be hard, and sometimes – despite our best efforts – we can’t catch a break. In those low moments, we need to lick our wounds and refuel our reservoirs. Thus, we all need to sulk sometimes, and we need to thoughtfully listen to ourselves when this need arises. If we disallow ourselves much-needed sulking time (and instead try to white-knuckle our way through all adversities), we are delaying the inevitable and making it more likely that we’ll eventually be struck down by a more crippling version of depression.

So when you need to lay on the couch, binge-watch Netflix, and eat five tacos, do it. But then get up the next day like a warrior – ready to regroup, dust yourself off, and fight.

Taco Tuesday only becomes a problem when it turns into Taco Wednesday and Taco Thursday and Taco Friday…

6. Play the right game on the right field

I come from a place where, if you want to be heard, you get loud and animated. This method for not getting punked was like a verbal version of making yourself appear big to ward off a mountain lion. Growing up in a particular context indelibly shapes you, and de-indoctrinating yourself is hard. As an adult, my verbal flares embarrassed my kids and mortified my husband, but when they challenged my tactics, I doubled down – justifying the means, irrespective of the ends.

Somewhere around 2010, I went into my son’s junior high school to confront the administration for treating him unfairly (e.g., skipping progressive discipline steps outlined in their handbook). I believed they were biased against him, because he had an IEP for dyslexia and other learning disabilities.

I remember the confrontation like it was yesterday: The administration staff sat behind the counter, and the vice principal stood behind them. I verbally flared – showing this “mountain lion” how big I was. More simply put: I went off on them. As I was colorfully making my points, I had almost an out-of-body experience. In one part of my mind, I was relaying what the problem was. In another part of my mind, I was observing their reaction – one of shock and discomfort. This part of my mind realized that they weren’t hearing a word I was saying. They were too busy emotionally reacting to my communication style. I also realized that the second I left, they wouldn’t give another thought to my points. Instead, they would all be relieved I was gone and gossip about this kid’s “crazy mom.”

As I drove away, I had to have some real honest conversation with myself: What do I want more? For things to improve for my son? Or to indignantly continue communicating displeasure the way I always had? Fortunately, I chose my son.

I then wrote a polite, but firm, letter – citing dates, facts, policies outlined in the handbook, and FERPA. I also thought about what would motivate them to change, which resulted in my letter advising them that another such infraction would leave me no choice but to contact the school board.

And then they changed.

This was a valuable lesson in my life, which permanently changed how I communicate. To effectively adapt, we must learn, understand, and implement the rules of engagement of our new environment. Even if I’m the world’s best basketball player, I’ll look dumb dribbling a basketball on a rugby field.

7. Beware false prophets

At every step along my journey, I’ve had people trying to convince me of what is “normal”…constant bickering in marriages, infidelity, struggling financially, hating your job, kids acting out. Each time I vented about something that brought me stress or unhappiness, someone was there to tell me that “everyone is like that” and that my “expectations were too high.” In my lowest moments, I actually believed them, which resulted in me feeling hopeless and made me feel like there was something wrong with me for not being able to be content with “normality.”

In a brief moment of clarity as a young adult, I remember waking up one morning and pondering on the fact that most of my friends didn’t have their own place to live, didn’t have a car, didn’t have custody of their children, and used drugs and alcohol daily. This realization was startling, and I asked myself if that was how I wanted to live my life. I clarified for myself that I wanted something completely different, which led to an abrupt and thorough reconstruction of who I surrounded myself with. I applaud this younger version of myself, because – while I was oblivious on so many fronts – I independently realized that what we are surrounded by is what we normalize. I didn’t want that lifestyle to feel normal.

When someone would subsequently say to me (about the topic du jour), “Oh everybody is that way,” I was quick to clap back with, “Well I don’t care what everyone else is doing.” I knew that – to survive and thrive – I couldn’t settle for what was in my immediate periphery. I learned to surround myself with people with similar values – people who were heading in the same direction as me (e.g., self-improvement, happiness, quality relationships, kindness, self-worth).

By the time I was in the Air Force and had a supervisor tell me that my “expectations are too high” regarding the performance and behaviors of my colleagues, I was completely unmoved. I knew my expectations weren’t too high, and I knew that humans tend to settle under the ceilings we set for them.

Bottom line: If we want to excel and continually improve upon the best previous versions of ourselves, we cannot buy into or be distracted by the naysayers who try to convince us to collect dust under mediocrity. After all, misery loves company.

8. Train for a marathon, not a sprint

Robert Strauss said, “Success is a little like wrestling a gorilla. You don’t quit when you’re tired. You quit when the gorilla is tired.” Beating the odds is usually a journey of endurance, yet we humans often lack the patience and perseverance to see it through. At every juncture, we should have already planned our next step, and we should know how that next step is a vital component of the end game.

I haven’t done this perfectly. When I declared psychology as my undergraduate major, I didn’t know that I couldn’t really do anything with that degree. When I entered my doctorate program, I didn’t know an internship was required to graduate. Naïveté isn’t sufficient justification to quit, however. At each new learning point and setback, I had to dig deep, recommit to my end game, and modify my plan for getting there. (Recommendation: Find a good mentor!)

Bigger picture (i.e., beyond just the tangible setbacks), however, is that every “success story” is built on the back of a long, winding, tedious journey. When we see success stories in the media, we see a snapshot of the outcome…the payoff. What we don’t see are the boring days, the lost sleep, the self-doubt, the naysayers, the commitment, the repeated defying of a comfort zone, and the perseverance. To become a success story, you have to have the fortitude to persist through every painful and non-flashy moment of the journey.

9. Be the best you

My potential-future-daughter-in-law, Lexi, has a very particular culinary palette. She’s a big fan of barbeque, chicken nuggets, chicken alfredo, and pizza. In contrast, my husband and I are foodies. We view eating as an experience and an adventure. Therefore, we’ll try anything with a tentacle once, and we’ll eat out of a truck or at a dive as quickly as we’ll eat at a five-star-restaurant. If I made a Venn diagram of Lexi’s food tastes and ours, there would be a small intersection set, but largely, they’d be non-overlapping. So if we’re wise foodies, we’ll consider that non-overlap when we get food recommendations from Lexi, and she’d be wise to cautiously gauge our food recommendations as well.

I use this (real world) analogy to highlight that we should use some discernment when listening to the opinions and advice of others, as we all have different personalities, preferences, strengths, and desired outcomes. What works for Barbara may not work for me – and vice versa.

All my life, I have (like pretty much everyone else) been almost suffocated by a barrage of unsolicited advice. People have told me that I should be more ladylike, more deferent, more vocal, more smiley, more fake, more…whatever. My grandfather told me on his deathbed that I should stop fooling around with school and be a stay-at-home mom. My graduate advisor pressured me to be a researcher – and also told me I shouldn’t try to be “clever.” An Air Force supervisor told me that if I was less “intellectually intimidating,” people would be kinder and more helpful to me. And so on. If I had heeded the advice and pressures of every person who heaved them upon me, there would be nothing left of who I am or what makes me…me. My individual strengths would’ve been completely suppressed.

To chart our own course, we have to get better at wading through and past all the pressures people put on us to live or be more like them. We have to identify the individual strengths that we bring to the table and effectively marry them up with our values. If we do these two things without fail, group-think will not derail us.

10. Don’t fear the fall

Well, maybe it’s not so bad to fear falling, per se, as us humans are pretty fleshy. But if we act and plan based on fear alone, our scenery is unlikely to change. We have to take educated risks, or we risk being stuck in a safe little rut our entire lives.

In my most recent leap from the proverbial ledge, I was preparing to leave active duty service in the Air Force and was at a crossroads on whether I should take the safe route of working for someone else (i.e., steady paycheck while I paid off my hefty student loans) or the risky route of opening a private practice (i.e., no guarantee of a paycheck and no guarantee of a viable business). I actually started leaning toward working for someone else “for now,” because I was growing weary of asking my husband to bear various career and financial risks with me. (The fear in the back of my mind haunted me with a barrage of what ifs?) Fortunately, my husband checked me: “You’re just delaying the inevitable. The goal was never to work for someone else, so you either take this risk now or take this risk later. Either way, you’re eventually gonna have to rip the band-aid off.”

People where I come from aren’t business owners. They’re the worker bees, and I too was raised to be a worker bee. (In high school, I longed for a stable, $10/hour factory job.) So venturing into this new land was foreign and terrifying. I had to look at that fear, name it, acknowledge it, and leap anyway.

Leaps don’t always come with a fall. Sometimes they allow us to fly.

Joye L. Henrie, PhD

 August 2018

No-Showing to Therapy: Is the Patient or Therapist to Blame?

The following is a modified excerpt from a leadership paper Dr. Henrie wrote while still serving in the Air Force. She shares it here as both a call to fellow mental health professionals and a spotlight shined to aid patients in better understanding their therapeutic process, which only stands to validate and empower patients as they engage in therapy.

Every group has its own nuanced culture. Mental health professionals are a peculiar bunch, and some would argue that we have to be peculiar to do the job we do. Perhaps that results in some ghastly senses of humor or wonky strategies for self-care. And perhaps that’s what we have to do or be to survive. Nevertheless, there’s tremendous room for professional and personal growth in our field. All things cannot be accurately attributed to the responsibilities or heaviness of our profession…or if we allow ourselves to persist in inaccurate attributions, we sell ourselves, and our patients, short. And shortcomings in the medical world can have fatal outcomes.

When I was a doctoral student, part of my training was working as a “clerk” (i.e., a supervised, student practitioner) at a private practice in the community. I had three supervisors there, and not one of them had demure personalities. Four and a half hours of supervision per week. Four and a half hours per week of critiquing my every comment, my every movement, my every reaction. Four and a half hours per week of being asked why I was so hard to read…why I didn’t “believe” the strategies I was being sold…why my life was filled with a series of one-way relationships. My early response was one of defense. I felt under attack and fraudulent. While sitting in sessions with my patients, I was sometimes distracted by thoughts of how I might be criticized for what I just said.

Over time, however, my guard started dropping as I gradually came to understand that there was merit in the feedback I received and came to witness how vehemently my supervisors wanted me to grow and succeed. It was the first place I had worked where I consciously recognized that my supervisors wouldn’t summarily cast me in concrete based on their first impression. These were supervisors that wanted to see me climb the proverbial ladder to success, and as I reached each new rung, they erased memory of the prior rung and celebrated the current version of me.

It wasn’t an easy clerkship, and I was certainly having a vastly different experience than my student counterparts. My clerkship emphasized introspection, hard conversations, and personal and professional discomfort. Yet the three years I worked in this clerkship permanently changed who I am as a person and as a professional. Perhaps most importantly, I learned to courageously look in the mirror and examine honestly and objectively my flaws and shortcomings, while simultaneously learning how these flaws and shortcomings insidiously crept in to the work of therapy.

In the mental health world, there is an unfortunate cultural phenomenon of placing blame on patients. One such way that my contemporaries do this is by blaming no-shows and treatment dropouts on patients. It’s common to hear mental health professionals say, “He wasn’t ready for treatment,” or, “She’s just being avoidant.” Frankly, it’s an easy and self-soothing dismissal, and the commonality of this trend allows each of us to comfortably regurgitate these excuses to stave off any professional responsibility of looking in the mirror. And who’s going to question us? We are allegedly the subject matter experts. We have advanced degrees…printed on intimidating-looking paper…hung in expensive-looking frames.

But my clerkship supervisors would allow no such mental laziness, professional negligence, or comforting lies. If one of my patients no-showed, they asked me why. I remember the first time I was saddled with this question, my internal reaction was, “How the hell should I know? I’m not a mind reader.” But this was my internal reaction only because I did not yet have the wisdom to truly understand the question. My supervisors continued to lob this question at me over time. At my next level of understanding, my internal reaction was, “Why are you insinuating it’s my fault? I can’t control what my patients do.” Again, this was my internal reaction only because I did not yet have the wisdom to truly understand the question. As my supervisors continued to mold and groom me (read: Chinese water torture), I eventually developed the wisdom to understand the question. What they were actually asking was, “What did the patient need at the last session that they did not get? What did you do differently? What was lacking that resulted in them not valuing their time with you? Were you fully present? Were you having internal reactions to them? Did they feel judged?…

Once I actually understood the question, it no longer felt threatening. It felt curious and purposeful. And I no longer saw the question as absolute. I came to realize that my supervisors understood that, at times, patients no-show or dropout of treatment for reasons we can’t control, but, at times, they do so because of us. My supervisors wanted me to first exhaust the possibility of my contribution before mentally casting blame on the patient. How can we be excellent, value-added practitioners if we can’t self-reflect or if we can’t understand our role and responsibility in our patients’ treatment investment?

A recent meta-analysis of treatment noncompliance (i.e., no-shows and premature dropouts) revealed a mean noncompliance rate of 42% (Defife, Conklin, Smith, & Poole, 2010). To put the economic gravity of that in perspective, the current TRICARE reimbursement rate for a psychologist’s hour of therapy (in my area) is roughly $132 (see CMAC procedure rates). So if a psychologist sees six patients a day, five days a week, the annual gross would be $205,920. If 42% of patients don’t show up, the psychologist’s annual gross reduces to $119,434. But that’s a rather selfish analysis.

More broadly, high noncompliance rates also mean that slots are “reserved” for patients who often aren’t using them, which results in new patients seeking care not being able to establish services, which is a serious problem in areas where there are shortages of mental health professionals. And if new patients can’t establish mental health services, they can’t get the help they need. It also means that the original patient, the “non-complier,” isn’t getting the care they need, which puts them at higher risk for myriad negative outcomes. And so on.

Countless researchers’ hours and countless government grant-funding dollars have been dedicated to trying to figure out the “vexing” problem of treatment noncompliance (Defife et al., 2010), yet these studies have largely examined the demographics or logistical constraints of patients who no-show. (Notice how patient-blaming that angle of analysis is.) Hell, even the word “noncompliance” suggests that we (the professionals with the fancy paper and fancy frames) order them to do something, and they willfully and belligerently disregard our orders. Only in the last decade or so are researchers starting to ask if something in the therapeutic process happens that results in no-shows. Lo and behold, they’ve found that “perceived disrespect from health care providers…, skepticism of health care service efficacy, and emotional discomfort or embarrassment” (Defife et al., 2010), for example, all contribute to missed appointments.

So back to what I learned in clerkship: My supervisors got me in the habit of asking myself why a patient missed an appointment…what I did differently or inadequately…what was going on with me that influenced the missed appointment. When I asked myself this question honestly and objectively, I was often able to identify the cause…things such as (brace yourself for some real-talk): being annoyed by the patient, being creeped out by the patient, being distracted by other things going on in my head, being emotionally rattled from some other event that just occurred in my life (professionally or personally), feeling lazy (poor investment), or remaining emotionally distant (often due to burnout or the strain of life).

The better I got at identifying my contributions to treatment noncompliance, the better I got at predicting when a patient would no-show to or cancel the next appointment. So I eventually got the message loud and clear. I came to believe that I am directly responsible for my no-show rates, and that my no-show rates are one metric by which I can gauge the quality and competency of my work. Once I acknowledged and took ownership of this phenomenon, my no-show, cancelation, and treatment dropout rates dropped dramatically, and at every place I have since worked, I have had the lowest such rates among my peers. In the Air Force, my average no-show rate was 5%, and in my first rolling year in private practice, my average no-show rate was 3%.

Sure, it’s hard sometimes to dig deep and be fully present and invested, but I remind myself of the consequences of not doing so. When it feels too overwhelming to think about potential negative, long-term outcomes for patients, I think selfishly. I think about the mess I’ll create by not doing the right thing…about the inevitable no-show, the inevitable arrival at the subsequent session, and the damaged relationship with the patient…that I will be responsible for repairing. And when I’m already feeling stressed out, the thought of having to clean up that mess sounds more taxing than doing it right in the first place. That keeps me honest.

Had I not learned the criticality of self-reflection from my clerkship supervisors, I’d likely have no-show rates similar to industry average. And I’d likely blame patients for those rates. And I’d likely feel professionally impotent to change those rates, which begs the question: What would be the point of practicing as a psychologist if I can’t identify the antecedents to and mechanisms of human behavior…including my own?

 

Joye L. Henrie, PhD

July 2018

 

Defife, J.A., Conklin, C.Z., Smith, J.M., & Poole., J. (2010). Psychotherapy appointment no-shows: Rates and reasons. Psychotherapy Theory, Research, Practice, Training, 47(3), 413-417. doi:10.1037/a0021168