Mental Health Monday—Swiss cheese and forgiveness


We all make mistakes. The feelings of regret, shame, maybe even guilt can plague and loom over us like a dark cloud. How do we learn to come out from that cloud? We need to eat more Swiss Cheese—the one, just like us, with all the holes in it.

Imagine a block of Swiss Cheese. You slice it into thin layers. If you wanted to, you could line up the layers of cheese so that you could pass a pencil through the holes.

The Swiss Cheese Model of Human Error was developed by James Reason (what a great name) to describe how one creates many different layers to stop serious errors occurring. Each layer or slice of cheese has a hole in it, a weakness. No system of prevention is perfect. So you create other layers of defense to stop errors occurring, but all the layers have potential weaknesses and holes. When all the holes line up then an error occurs.

How does this help with forgiveness?

Well, take a serious look at a mistake you have made, maybe get a friend to help you with this who can be objective about it all. Take a look at all the things that led up to the mistake happening. Often it will be a combination of holes aligning to let that error through. Some of the holes may not have been anything to do with you. It may have been the responsibility of someone else. All that you can be responsible for is what you did, your layer.

Here’s an example. A road worker dies when a car hits him on the side of the road. You were driving the car. This memory haunts you day and night. An investigation of the accident is done. It looks at all the factors of the crash. They research every layer of protection that was there to safeguard the worker from being hit.

They discover that:

  • Many signs warning you of road work ahead were not put out
  • The road was wet
  • It was dark, making it difficult for you to see
  • Your brakes were slightly faulty because the mechanic who just checked them wasn’t qualified
  • Your car hit a nail just as you came around the bend towards the road work.

Bottom line: layers of protection had holes in them. When they all lined up the catastrophe was inevitable.

Who or what was to blame for the worker’s death? It was a combination of faults. After the investigation was complete the layers of protection were altered; for example, new rules about signage for road work, mechanic training became mandatory, etc.

How does this help with self forgiveness?

I think it’s vitally important to analyze the big mistakes you have made. Look for all the layers that could have prevented these from happening. We can’t go back and change things. We can only go forward with new insight. John Maxwell said: “Experience is not the best teacher; evaluated experience is the best teacher.” Forgive yourself for your part in the error. Forgive others for their part in the error. Allow God to reveal to you that no human system is perfect.

Be forgiving!

—Barry Pearman

Originally posted 2016-03-21 08:17:50.

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