Sunday, September 15, 2013

The Pillar Metaphor

The Pillar Metaphor

We use lots of metaphors for talking about mental health. Lots of models, lots of approaches. Like different camera lenses, they all offer a slightly different view that, ideally, helps us see a little more clearly.

I was talking about suicide intervention tonight, and a pillar metaphor came to mind.

Imagine that you're building a house on ground that's very wet. Digging a basement isn't going to work because it's too wet, so you dig deep and set support pillars into the soil, bedding them as deep as you can. Once these pillars are in place, you build a pad atop them, and above that you build your house. That house is your life. You live in it, you work in and on it, you invite people into it... you live in it.

As long as things are stable, you probably don't think much about whether your house is stable or not. It never attracts your attention, so you don't notice whether your house has a lot of support or just barely enough--as long as there's enough, you're good. And as long as things are stable, you probably don't spend a lot of time poking around underneath to see whether all the supports are in good working order.

This is normal.

There's a fine line between proactive maintenance and obsession. Nobody's suggesting that you should spend all your days under the house checking out the pillars, making sure their concrete is sound, clearing cobwebs, or anything. But neither is it a good idea to let your supports go too long without checking in--because otherwise you only learn about problems when you lean on the supports and they crumble.

So you've got this house, which is the metaphor for your life. At any given time, it has a certain amount of stress or strain1, which is like the total weight of the house and its contents, etc. In real life, this is the normal stuff of every-day life: family, health or illness, job, friends, the person who shoved you in the grocery store, the toddler who offered you a flower on the way home, the feeling of waking up after a good night's sleep, the lingering smell of burned toast, the questions about paying for retirement or college, the block party, all that stuff. Nothing world-shaking, nothing too far outside the ordinary. If your house was designed well and is in decent repair, you've got plenty of support for this stuff--so nothing bad happens.

But sometimes a storm comes along and trashes things. Maybe it comes with gale-force winds, which push really hard on your house's walls and (effectively) add weight to the structure. Maybe it floods the soil and then lashes it with wind, which destroys some pillars if it lasts long enough. We all know what storms look and feel like; they're the big things that hurt. Deaths, job losses, serious injuries, relationships ending... big stuff. We'll call this stuff a storm factor. (Sometimes good things can be storms, too--ask anyone with a new baby).

      Strain = House's weight * storm factor

Let's say that your house's resilience is a function of its number of pillars. Basically, it can resist a certain amount of strain, for a while, if it has enough pillars. Since pillars can be different sizes, and can also be in good or bad condition, we'll add a factor to show how strong the pillars are.

     Resilience = number of pillars * pillar strength

As long as resilience is bigger than strain, everything is fine: the house stays up, nothing shifts, and the occupants are usually pretty oblivious to the balance. But if strain creeps above the resilience threshold, even just for a moment, things start to crack. Maybe the pillars start cracking, and that pillar strength factor goes down, lowering total resilience for next time. Maybe the house starts to tip a little bit, and furniture starts falling over. It's still salvageable, but things are pretty tough. This is where we start a lot of the interventions in the mental health and substance abuse worlds. Seems a little late, don't you think?

If the strain becomes a lot higher than the resilience, the house just buckles on its supports and falls down. At that point, it's going to require heroic efforts to save it at all, and it may never go back to quite the way it was even if we succeed. This is where a lot of people enter the mental health world: in the midst of a suicide attempt, at a psychotic break, or hitting "rock bottom" on substances. There's still a great deal of help we can offer these people at this point, but on some level we're now talking about disaster services, which are tremendously expensive and resource-intensive.

About those pillars...

Let's revisit those equations I posted up above.

     Strain = House's weight * storm factor
     Resilience = number of pillars * pillar strength

Which factors can we control? We can have a small effect on the house's weight--we can take a more- or less-stressful job, add or subtract relationships, etc., but a lot of the stuff in the house isn't really under our control. We can't do anything at all about the storm factor, because accidents happen and we can't stop them.

What about the pillars? For this argument, I'll say that most of our efforts work on increasing the number of pillars we have, and that pillar strength is largely out of individual control. (This is handwaving. Bear with me.) If you think your house needs more support, you can go out and find some. Maybe it works something like this:

     Good family relationships --> you get 5% more pillars
     Good health --> you get 5% more pillars
     Mental health care --> you get 5% more pillars
     Faith community --> you get 5% more pillars
     Stable job --> you get 5% more pillars
     Nice neighbors --> you get 5% more pillars
     ...  and so on.

The more of these you stack up, the higher your resilience value is going to be. Remember, this won't matter on most days, because your house was designed with enough resilience for its intended normal load. But the more extra pillars you get, the bigger a storm has to be before it can knock your house down. You can weather the storm (forgive me) with way better odds.

But it's not all positive. We can look at a lot of the conditions we work with, in terms of pillars, as vandals that go in and sabotage your foundations under cover of darkness. They go in and mess with the pillars and, again, under normal conditions, you may never know until things get really bad. But eventually, this stuff can weaken the foundations to the point where even normal life exceeds the rated strength of the foundation:

      Schizophrenia --> knock down 20% of your pillars
      Chronic illness --> knock down 10% of your pillars
      Alcoholism --> knock down 15% of your pillars
      Lyme disease --> knock down 15% of your pillars and put up paper replicas to hide the empty spaces
      Loss of loved ones --> knock down 5-50% of your pillars
      Poverty --> knock down 65% of your pillars and require monthly rent on the others
      ... and so on.

So what's the point?

It's not easy to see the foundations of things. There's usually a lot of stuff piled on top: a house, a history, a life. Even with a lot of introspection, it's hard to really know what's going on under there unless things start falling apart. We just know one simple thing: it's strong enough, or it isn't.

Not everybody even starts with the same number of pillars. John D. Rockefeller had some advantages compared to the people living under bridges, and we can think of these in terms of how many pillars of support they started with. Some people just get wired in ways that make them seemingly happy all the time; many of them got lots of pillars at the beginning. Some people come from horribly disadvantaged backgrounds, have very few pillars, and still do fine--we can think of  this as having a few pillars with huge pillar strength factors.

But we often forget that people's life conditions make them more exposed to instability, or we pretend that it's all about willpower. How many times have you heard someone talk dismissively about an alcoholic who starts drinking again after a year in recovery or a mentally ill person who "loses it"? Heard someone tell a suicidal person not to be so selfish, or a schizophrenic that if they just try harder, the voices will go away?

Would a contractor say "well, your house wouldn't have fallen over if the foundations had tried harder"?


I'm not trying to say that willpower is unimportant, but I think it's overrated. A lot of the problems our clients and callers face are saboteurs: they destroy the underpinnings for a stable life. Is it any wonder their boats are sinking when they've got so many stowaways drilling holes in the hull? Is it the house's fault that it falls over if half its pillars are gone?

I'd like to see our behavioral health professions taking a more compassionate look at people's circumstances. Real empathy starts with seeing people the way they are, and respecting what's possible for them. Not everyone gets to have a house with tons of extra pillars. Some people's houses fall down. Sometimes their choices lead directly there; sometimes they've tried good things but been overmatched; sometimes they succeed in shoring up the foundations. But when the strain outweighs the resilience, we shouldn't be surprised that things fall apart.

So that's the pillar metaphor: a new lens for seeing stability.

1: Yes, I know that my use misuse of 'stress' and 'strain' is probably giving the engineers in my audience conniptions.  I'm sorry. Maybe you could use this moment to notice that my misuse of terms has momentarily increased the stress in your life (did you see what I did there?) and that your support pillars are under a bit more strain just now. Perhaps this will provide the impulse you need to force yourself to display a little more toughness in your relationship to words with linkages to multiple meanings, or maybe you'll just think I'm a jerk. :-)