Why I’m not pessimistic about councils’ response to vaping in the workplace

This past week has seen a continuation of different aspects of the debate about e cigarettes.  Neal Roff’s helpful and thoughtful blog for people new to using e cigarettes http://stormchildsblog.blogspot.co.uk/ was published.  And the equally helpful UKCTAS report on a depressingly “bad science” World Health Organization position statement was published http://ukctas.net/news/commentary-on-WHO-report-on-ENDS&ENNDS.html

But I want to turn to the report published over the last few days by  freedom to vape¸ http://www.tfa.net/freedom-to-vape/  a campaign of the Freedom Association http://www.tfa.net/about-us/

This report details the results of responses from local authorities to Freedom of Information Requests about vaping and smoking policies, sent earlier this summer.

“Councils ignoring PHE advice”

The report headline on their twitter feed says “87% of councils ignore Public Health England advice” on vaping being treated differently  You can read their comment posts and the report here http://www.freedomtovape.net/new_report_from_freedom_to_vape_87_per_cent_of_uk_councils_are_ignoring_advice_from_public_health_england?recruiter_id=107

Separately, another blog called vapers in power has published a blog linking to the “write to them” website encouraging people to write to local councillors about their policies https://vapersinpower.wordpress.com/2016/11/06/changing-how-your-council-sees-vaping/

Meanwhile, Simon Clark of FOREST has also written about this campaign on his blog http://taking-liberties.squarespace.com/ giving a different take.

Finally,  a report claiming – implausibly in my view and that of several lawyers I have spoken to – that councils are using “illegal” vaping bans was featured in The Mirror on 5th November http://www.mirror.co.uk/news/uk-news/illegal-vaping-bans-mean-third-9204911

Helping or hindering?

Transparency is always good, and indeed it’s helpful for citizens to write to their elected representatives giving their views on issues like this. I also note that the transparency of councils in Freedom of Information requests is far greater than the transparency of some agencies commenting on this, and the story is being used by some to bash councils and public health. I think that will prove counter-productive and some councils at least will decide not to tread on what feels like an increasingly fractious and flammable path, even if they can see good at the end of it.

One DPH recently told me anything they say positive is met by some people on social media – who really don’t represent vapers but many folk wouldn’t know that – with tweets about them being evil and how public health and tobacco control want shooting.  And then we wonder why public health folk are keeping their heads down in this debate.

The FTV report, while useful, doesn’t tell the whole story

There are several reasons why I don’t think the latest freedom to vape report tells the whole story. Doubtless some will disagree but let me list my reasons why:

  1.  The PHE report which contains guidance for workplaces https://www.gov.uk/government/news/vaping-in-public-places-advice-for-employers-and-organisations was only produced in July 2016.  The Freedom to Vape policy report was issued this past week. That’s just over three months between PHE guidance and the FOI report. The idea that most or even some councils will have considered, read and changed their policies on workplace vaping in that period is optimistic in the extreme, to put it mildly, given everything else they have on.  The Freedom to Vape report can’t be taken as more than a snapshot of what the position was at the time of the FOI. For many councils this will be in a queue of issues to deal with, and breaking even will be top of the list.
  2. How can I say that?  Because I know personally of a number of local authorities who are currently in discussion, or drafting revisions of policy and using, among other sources, the new PHE guidance and work from CIEH and others as a support. We are currently working on ours. I’ve commented on a few, and indeed many have commented on our draft policy.
  3. FOIs are an industry. Most local authorities employ a team to answer them. And I suspect (indeed having had informal discussions I know) that some councils have had their FOI team look at existing policy on the intranet and answer the FOI from freedom to vape. This won’t have captured that nuance. And it wont have captured those authorities where discussions have taken place but nothing is being written yet. The freedom to vape report, in that sense, misses out some work going on.
  4. You may say the FTV report will only miss a few local authorities doing positive policy development.  But local authorities tend to be pack animals. They watch and learn what others do and follow those they think are best, especially in an uncertain area.  And I know from speaking to people across the country that this is exactly what’s going on here. The few will shape the response of the many, in time. And three months is not enough for that to happen.
  5. It will take time, because there is no statutory duty on local authorities to do this, no policy obligation to do it either and the PHE guidance isn’t binding. Local authorities have discretion here and the key for people who are pro e-cigarettes is to help councils and support them use evidence and guidance sensibly and wisely. Frankly, the state of this debate will make some councils wish to exit the debate because it begins to look like a thankless low priority task when they’re about to fall off a financial cliff.
  6. Given everything else on the corporate agenda of councils (finances, social care, moving to business rate retention, devolution and so on) we need to find ways of making it easy for councils to do this. No amount of opprobrium and campaigning will make councils prioritise this if they think all they’re going to get is noise and hostility – even if it’s only from a few and the intention behind this report was about doing some good for peoples’ health.
  7. Several multinational tobacco manufactures have developed new, potentially risk reduced tobacco products which heat the tobacco but do not burn it. The Committee on Toxicology has been commissioned to evaluate the available evidence and at least some councils will probably  want to await this report before making any definitive statement or revision of policy.  Independent evidence on this latest development is extremely scarce but a study by the Dept of Public Health at the “La Sapienza” University of Rome suggests that it may be more appropriate to treat these products like e-cigarettes than to treat them like smoked tobacco.  What is likely is that councils, given everything else on their agenda, will not want to revise their policies several times within a year.

But there is a wider issue here, surely?  Why focus on just councils?  What about NHS, civil service, other public sector and commercial and NGO/third sector employers?  From what I can see and the discussions I’ve had with local employers, many of them don’t seem to have moved very far since July either. That’s because this shift will take time. The HR world is still in many places working out what it means in terms of employment law and local workplace policies and contractual entitlements.

Don’t just dismiss the FTV report

There will be some who dismiss the FTV report as a hostile publicity stunt, done in haste and poorly thought through. That would be a shame. And that’s a line I am neither going to believe nor support. The report was done by people passionate about the benefits of e cigarettes, I believe done for good intentions, and it does give us a snapshot of where councils are at and where the opportunity lies. The task now is supporting the HR community with getting on with this.

Time to re-orient how we debate with one another

I worry that there is a danger that some councils will see the report through the lens of some quite frankly hostile social media coverage (some from people who don’t like local government anyway) and decide they will wait and see what others do rather than trying to change things and get even more opprobrium.  To that extent, there is a real possibility that some of the social media coverage around this may backfire.

There is a whole discussion about people saying public health and tobacco control are fit for nothing, well I’ll address that another time.

Some factual corrections to the recent debate

There’s also some factual things to correct here:

  • Media reports that PHE advocates vaping rooms are not correct.
  • PHE has avoided prescriptive guidance and has proposed 5 criteria to help form local policies. The fact they have avoided prescriptive guidance means employers have to rely on their own interpretation of the law and their local contracts. The idea that most or even many employers will manage this between July and end of October is a triumph of hope over reality.
  • A conversation with a knowledgeable employment lawyer this morning told me that they and their legal colleagues have met with derision the media claim that local authorities are acting unlawfully on this. As someone who has worked in HR, I personally cannot see the legal claim for this. Employers remain able or not to consider whether or not to allow vaping.
  •  Establishing a right to vape in law will be very difficult, and would undoubtedly need legal precedent

Where next?

The adoption of the PHE principles will take time. We’ve been working locally on our policy for several months. That wasn’t reflected in our FOI response to this. This is not cause for anger or depression.  Nor is it cause for trading insults. We need to take the heat out of this debate.

There are lots of challenges lying ahead in developing and taking an evidence-based approach to welcoming e-cigarettes and similar devices. Setting to each others’ throats or “bigging up” an issue as a legal one when it isn’t – at least not in the way some folk report it – is not a recipe for elucidation.

 

 

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Mindfulness…useful, not a panacea

Thinking of using or commissioning something involving mindfulness?  Good, but have a think about what it is you are trying to achieve.

I like mindfulness, I think it has a number of applications. While it comes from faith traditions, Mindfulness type techniques are increasingly found in non-faith settings. Why? Because Mindfulness seems for many people to have salience and usefulness in a range of situations including living with chronic illness, coping with stress, and coming to acceptance of one’s own identity.

Pace, for example, say it has value for LGBT settings and people among a range of other techniques and tools. It has been applied in long term conditions like neurological conditions and in Hertfordshire currently this is being researched by clinical psychologists.  At its heart mindfulness points us to the need for balance in our lives and relationships, both interior and exterior. And we should welcome this as a good step. Try the Royal College of Psychiatrists site for some good resources.

Mindfulness and cognate spiritual traditions: the balanced life

You may not think to look at or listen to me, but silence and contemplation are things I try to practice for a period each day. (Ok, stop falling about laughing, I am actually being serious. The experience of being centred each day on the relationships and the things I value are essential to me. As a Catholic and someone with an attachment to the Carmelite tradition I call this an aspect of contemplative prayer. As a psychologist I call this focusing using techniques which are essentially similar to mindfulness.)

And in the 500th Anniversary of the birth of the Spanish Mystic Teresa of Avila  (the great Carmelite reformer) it seems a useful time to take a look at some of the stuff,  healthy and not so healthy, which seems to be trending on mindfulness. Like any good thing which is trending, it seems that in the midst to rush and take up mindfulness-based techniques, we are busy both forgetting some of the things about its origin and tradition we should bear in mind, and at the same time not overtly doing the work of finding a framework into which we can place mindfulness as one of the tools for a balanced life.

Lessons from the origin and tradition

Mindfulness is NOT purely a Buddhist concept.  Almost every major faith tradition has some form of focusing or contemplation with methods, insights or rules similar to mindfulness. I know it’s enduringly trendy to see Eastern philosophies and religions as more simpatico to our atomist 21st century ultra diverse lives, but even in Christianity alone I could point you to multiple Catholic, Anglican, Presbyterian and other traditions akin to Mindfulness, starting with Early Monasticism and working through Carmelite and Quaker mysticism.  The Practice of the Presence of God, for example, is just one offering from 17th Century France.  And the Jewish and Muslim traditions are just as rich. Rant over.

A good thing psychologists have done is extract what seems to be a core of Mindfulness based technique and apply it to settings without explicit religious or spiritual overtones. That means it can have a wider application for some who find the religious or spiritual overtones off-putting or difficult.

But there is something being missed here…most religious traditions which have had techniques analogous to mindfulness for any length of time have developed in tandem with them tools and tactics for when all does not go smoothly with meditation type techniques. And this happens more than you might think. Miguel Farias and Catherine Wikholm writing in  New Scientist  on 16th May 2015 point out a range of downsides to mindfulness for some people – increased stress, anxiety even significant emotional and psychological difficulties.

What’s going on here?  Simply the fact that Mindfulness isn’t for everyone and some people collide into what in one Catholic (Carmelite) tradition is described as the dark night of the soul ; a period of aridity, darkness, futility, depression and loss.  Another form of what is going on is that if you really deeply hate yourself or have many unresolved issues, then mindfulness can bring you face to face with things you really may not like about yourself, feelings you may not always attend to, or may even supress. And when they are there in front of you, it can sometimes be overwhelming.

Using mindfulness in someone who has a life-threatening condition can bring them to the reality of their mortality in a way which can actually be overwhelming and cause panic, not calm, if you don’t help and prepare. And for some people with long term conditions, mindfulness can bring them face to face with their frailty and limitations rather than help them cope.  Some research seems to suggest outlook and personality factors could be important in determining when mindfulness helps and when it doesn’t. But as yet the traditions built up over long experience seem to have a handle on this which psychologists applying mindfulness are still to fully reckon with.

Spiritual traditions have ways of dealing with these issues and experiences, built up over centuries. Mindfulness-based techniques taken out of faith settings may not have.   But they need to develop them. Techniques like recognising when some people should be steered away from Mindfulness, how to build support in if aridity or desert experience or painful things come up are all important. And some practitioners and teachers both from a spiritual and non spiritual background do not seem to apply these safeguards.

We can add to this the fact that despite some neuroscience and some experimental psychology studies, we still don’t really know exactly how mindfulness works. We still are not yet fully clear of the mehanisms of mindfulness in a way we can really explain. This means we still need to be open to learn about where Mindfulness-based techniques are and are not useful.

I believe Mindfulness is not for everyone, contrary to what some commentators say. If you absolutely hate yourself, then training to focus on that and being left to sit with that can be devastating for some people rather than a spur for development. There can be a core of mindfulness type techniques that are probably very broadly applicable (focus, being in the moment, dealing with various cognitive and interpersonal demands across the day by focusing on the present) but let’s not assume this is a panacea. We did that with Nudge and got disappointed, and sometimes ended up using nudge less than we should have, just because it didn’t do everything we wanted it to.

Integrating Mindfulness into a coherent picture

It’s interesting to me that all the teaching sessions I have been asked to do on mindfulness in the last year were focused on how to integrate mindfulness into a public health, or psychological, or religious worldview. The most recent one was a study day for a mixed group in St Albans Cathedral (psychologists, public health types, therapists, ministers and others) which showed roughly similar issues across these disciplinary boundaries:

  1. An interest in mindfulness
  2. A knowledge of some of the techniques, sometimes very advanced
  3. Limited or little knowledge of what science there is behind it or even how mindfulness interacts with the biology of stress
  4. A searching for how to integrate mindfulness with their worldview, professional values and practice

Being clear about why you use or commission mindfulness is hugely important. We are not in a supermarket here, and treating spiritual or non spiritual forms of mindfulness “type” work as a “pick and mix” risks instrumentalising the technique and ourselves, and trivialising the issues behind mindfulness.

Having an eclectic methodological disposition in practice of psychology, public health or pastoral care is all very well. But not examining the fundamental assumptions behind a tool or technique means you can end up at best being inconsistent between values and practice, and at worst harming yourself or others because of the dissonance caused by that inconsistency.  If you believe everyone should use mindfulness to look at themselves, you have to put in place things to respond and keep people safe when what they see is something they find distressing. Equally, if you believe stress at work is at least partly or even mainly due to poor psychosocial work environment (and there is some good evidence to support this as at least one major factor in workplace stress) then mindfulness as the only answer is a cop-out, placing the onus on the employee when the solution really requires the organisation to change or act. Using mindfulness to make people more resilient to systems which dehumanise or dysfunction – whether care, education or employment – is neither ethical nor sustainable.

Kate Williams, writing in The Psychologist says that she is ” a strong believer in MBIs and can see the benefits it can bring. Yet we must remain ‘mindful’ of how we promote and talk about mindfulness to ensure we carefully promote its use and application to mental or physical health issues whilst in the early days of its research. If we can avoid overstating mindfulness as a gold standard or panacea, those new to mindfulness can start to practise with realistic expectations, under suitably qualified courses, and can begin to experience the wonderful world of mindfulness meditation.”

So, use mindfulness, but think aboutthe developmental nature of this field.

 

Leadership…it’s not all transformational in public health

I don’t know about anyone else but when I was training in Public Health, things like leadership education were largely missing. I was lucky to get onto the national Public Health Leadership programme over a decade ago now, and even luckier to have other training.

And yet leadership is an absolutely central function in public health, and leadership across systems especially. http://www.slideshare.net/jamesgmcmanus/leadership-and-ds-ph-update-oct-2014

You’ll be aware from a pile of postings, articles, slideshares and other stuff that I have an interest in (obsession with?) leadership in public health.  This is at least partly due to reflections on my own failures and a desire to try and get it right. And it’s partly due to my training as a psychologist. In the last few months I have reflected again on my own leadership roles but also have done a number of sessions for new public health leaders.

One thing I have noticed is that Transformational Leadership models seem to be the flavour of the month at present. I have found transformational leadership models, especially when adapted to the public sector (e.g. the work of Beverley Alimo-Metcalfe on local government) very helpful. Try these links for more reading on this:

The last link above on Post Francis enquiry approaches is especially interesting.

But there are some challenges with Transformational Leadership models, before we go running down the road to apply them in preference to anything else:

  • Some commentators feel transformational leadership is better in an organisation. When you work across a whole system, as public health leaders need to try to do, there are additional behaviours, styles and tactics you need, and you need to flex your style much more as a system leader across different organizational cultures than just transformational models would suggest
  • Transformational leadership training is not always good at explicitly integrating the scientific background of public health senior roles with the leadership tool portfolio they need
  • There is a very thin line between transformational leadership and dictatorship or bullying. Engaging people in your system and organisation is hugely important with transformational change and leadership and rightly many researchers are now emphasising this.  Beverley Alimo-Metcalfe, who created among other things the Local Government Transformational Leadership questionnaire, has spent a great deal of time on the importance of this.

Dennis Tourish’s new book The Dark Side of Transformational Leadership (Routledge, 2014, £24.99) is a salutary read on the strengths and weaknesses of Transformational Leadership as a model and theory.  He presents a significant amount of research on transformational leadership and case studies. The book has a good style, discussion questions and reflection questions and if you’re looking for a CPD text then do yourself a favour and give it a go.  Even if you only read the last chapter on new styles of leadership and better ways of thinking about leadership.

But he makes a range of important points that Public Health leaders who are attracted to transformational styles:

  1. Tourish spends some time in his book looking at the (usually catastrophic) consequences of leaders with vision whose decisions have not been challenged or helped to mature by being reflexive or open to others. There is always the potential that leaders in trying to transform do as much harm as good
  2. Unregulated power in a leader (I’m sure many of us have been there, on whichever end) is not a good thing and a key part of leadership in a system is about being held to account as much as holding to account. Leadership seen as service, as enabling a system is better at that
  3. Transformational leadership models in people who think they know better than anyone else can become a justification for arrogance. Public Health has not always been a stranger to that arrogance about its role, importance and abilities.
  4. Transformational leadership which is all about the leader and not about the team or organization or structure can have, like any leadership style, profoundly negative consequences on others.

Transformational leadership has its place. But if you are a public health leader in a system which doesnt want you, or is dysfunctional, or where others think they know your public health job better than you, then I am unsure that transformational leadership is the solution. An adaptive style which enables you to assess situations and use a menu of styles, tools, tactics and mechanisms is more likely to be helpful.  And indeed much recent research on leadership seems to be showing that across mutliple context systems that works. http://www.slideshare.net/jamesgmcmanus/adaptive-strategic-public-health-leadership

Trying to apply this is an interesting process, and I sat down one day with a group of colleagues when we were sharing challenges and perspectives. I have some rules of thumb on leadership which seem to be working at present:

  1. There is no Perfect style or perfect leader:
    • I will never be a perfect leader and there will always be fallout from what I do. But thats not an excuse not to do better. Doing better is the whole point
    • There is no single model of leadership which is right.
      1. The best “model” (or rather frameworkk which enables us to take different bits of different models) I can find at present is that of distributed, adapted leadership which is about leading systems. It takes in a range of elements including the transformational. You can find my presentations on this here   
      2. Leadership is a journey towards being authentically you and truly effective. That journey never ends and we can all always do better
  2. As with all public health, science and art must be held in dynamic tension to be effective and authentic
    • The science of leadership, good solid psychological science, needs to be taken seriously. But the more science I read on leadership, the more I realise it’s just as much art as science.
  3. Sources of reading and learning
    • Do yourself a favour and check out reviews in decent journals like  Harvard Business Review, The Psychologist or Management Today rather than buying blind in a book shop
    • Rarely trust anything you buy in an airport book shop
    • Do Read Harvard Business Review (even if you do find it in an airport bookshop)
  4. Models can be deceptive
    • If a model or course sounds too good to be true (you will become an amazing leader in one day) it usually is.
    • Be sceptical of people who espouse a model of leadership but have never led in your context. (If you haven’t spent a day in local government, how do you truly understand the context? .)
    • Models will change and my learning and style should change as knowledge develops
    • Over-reliance on one model is usually unhelpful because it limits your grow
  5. Think of Frameworks not models
    • A framework tells you what sets of thing you may need to be doing rather than prescribing “this is how you do it”. These rules of thumb are my framework
    • Ethics, Values, Vision and Context are as much a part of any good framework as tools and tactics and inventories
  6. Leadership cannot be context independent and be effective
    • Leaders are set into not apart from the contexts they serve (so the “independence of the DPH” needs to be handled carefully here).
    • Beware the “high” doctrine of leaders as great individuals. The context and the people make the leader as much as the leader.
  7. Leadership is a service to the common good or it is nothing
    • Leadership is a portfolio of influencing skills and tactics to get to the common good (ok this is my bias, but I bet you have one too)
    • That desired good will always be changing, like everything in life
  8. As the recent Kings Fund report suggests, as a leader across systems you need to be comfortable with chaos. Please note that my and your leadership style creates at least some of that chaos anyway!
  9. Dont expect people to be gentle and trusting of your leadership style if you cant spend some time being gentle and trusting of you and them
  10. Four golden functions: Nurturing, Guiding, Healing and Reconciling and Discipline (I dont mean sticks I mean holding a line and standard to keep people to) are important in leadership, and you need to be a receiver as much as a giver of these
  11. Leadership always has a dark side or down side
    • It may be just the fallout from your style. It may be just the dysfunction of being human and imperfect. But leadership ALWAYS has a down side, at least for some of those your leadership touches. If we don’t deal with this openly and work out what to do along the journey then our leadership is unethical.

Anyway, these are the things that help me. It may be different for you. Let’s help each other on our journey.

Public Health Leadership: the conversation continues

Having been working on leadership styles appropriate to public health in the new English system, I thought it was about time to share the results of some of the conversations I’ve been having, since the last time I posted.

I’ve had conversations with a range of people about leadership and DsPH and domain skills and way back in 2011 there was a colloquium on leadership and local government at which I presented from an organizational psychology perspective and as a DPH in local government, about the leadership styles and roles of the DPH. You can find this here. http://www.sph.nhs.uk/what-we-do/how-we-can-help/local-government/lg-colloquium-1

My perspective

I come at this as a psychoogist, who is CIPD qualified and qualified in strategic learning and development. I have been involved in leadership development in local govt, nhs, third sector and faith settings since about 2000. I started doing leadership development for community safety managers in local government at the time, on secondment to the Home Office.

I’ve also done leadership development in third sector, faith and safeguarding contexts, including work on self-care for leaders.

Most importantly, from my perspective, I found a lot of the models then being discussed not very helpful for a number of reasons. Some models being advanced were too focused on technical competence. Others focused more on “holding the ring” , while others seemed to suggest a largely transactional style focused on statutorily defined functions.

I argued at the time that we need a larger model of different domains for public health leadership, and three years (and many workshops, seminars, learning sets and my own reflection on my leadership style) later, I still think that multiple domains of competence for leaders are where we need to go.  My own colleagues and teams may tell you I am good, bad, rubbish or (as I think myself) a mixed bag on my own leadership. Personally I think as leaders we are always “on the way” and need to reflect and learn as we go.

So I set about doing three pieces of work. The first was developing further the work I presented in 2011. The second was doing some work on what types of leadership “style” might be suited to public health leadership today. The third is working with ADPH and others to develop some specific “content” for public health leaders – like the seminars on understanding how local government law is crucial to working in local government these days. I hope to do more of this content stuff.

Developing future leaders is different from supporting existing ones

Public Health England have been working with a number of other agencies to produce a  programme for future public sector directors (which I think will be excellent), and will focus on building new leaders and directors across childrens’ service, adult social care, nhs, local government and public health together. This could be very powerful at integrating  and producing leaders working across the whole system. But while this is excellent, we still need some work to develop further and support existing public health leaders.

Why existing initiatives may not work for current senior public health leaders in local government

My own view is the leadership models from the NHS and those proposed by a number of agencies don’t work for the following reasons:

  • Existing models and programmes don’t necessarily incorporate the multiple domains of skill and competence the DPH needs to show to be effective
  • Another major area is how to influence across systems, when many DsPH have been trained to be technical not system leaders and some are better at it than others. Similarly the training scheme doesn’t always prepare trainees to come off it ready to do this at the level they need to in local government.
  • A third area is the domain specific knowledge and competencies for local government which need to be added to technical public health domains.
  • A fourth area is partnership and system wide distributed leadership skills, which some have more of than others.

Another point about my own experience is important here, because it has influenced me significantly. When I started in local government in 1990 (so I have been much more and longer a local government officer than an NHS one) as a new Principal Officer (as we were called then) I got sent to London or Manchester once a month for three years for a programme on skills for local government management and leadership. This ranged from technical skills (local government law) to the crucial skill of understanding the members and officers of the local authority [or even department within the local authority] I would find myself in, understanding the culture and knowing which styles of influencing and working work and which styles don’t. This was essentially a senior local government finishing school. It was the best programme I ever did. It’s a programme I wish someone had run for me as a new DPH and it’s a programme I know a lot of existing DsPH would find valuable.

It also helped me understand when to stop wasting my time in a role I would never fit and move on when needed. Not every public health leader or local government leader is right for every local authority. The issue of “person-organisation fit” was something we can easily conclude is more important in local government. But in reality it was important in the NHS, they just dealt with people who didn’t fit in different ways to local government.

Understanding leadership from the inside

The literature on leadership development is littered with reflections from people who have designed programmes have done so from “outside” the system they are looking at in one way or another , which means a particular view of what is needed or a particular solution is chosen without necessarily investigating it thoroughly from the inside out.

One of the common themes in conversation with DsPH is that a number of programmes for us seem to have been designed from “outside” the context DsPH are now in, so miss a number of issues. We need to understand the challenges from “the inside” to design effective development and programmes. Listening to DsPH in local government is going to be crucial to design effective programmes for them. Equally, helping people in local authorities and people in Public Health England learn about the other by immersing them in each other’s agencies is potentially very useful, and is happening in a number of areas with PHE people and local authority people shadowing each other. This kind of exchange can only be good.

But the issue of leadership style still needs to be addressed. There are many common areas where people across the system can do some similar work on leadership styles. But I can’t get away from the feedback I get that specific work around public health leaders in local government is still needed.

Some potential solutions from Occupational Psychology and Leadership research

So, onto the specific pieces of work. Again I stress this is “on the way”. The history of research on leadership had been typified by a range of paradigms, models and concepts which have changed, dialogued and developed over time. The “leaders are great men” theory, common in the early thirties, is one few people would seriously subscribe to now. But a bewildering array of models from trait theory, servant leadership, transformational, transaction and situational leadership to diversity leadership all exist, with varying challenges and problems. And all of them attract researchers and practitioners for different reasons. My own take after years of working on leadership is:

  1. Leadership is a set of influencing tools and mechanisms applied for a given purpose in a given context
  2. The ethical, interpersonal and intrapersonal aspects of leadership are as important as both the task and the situation/context
  3. Many models can be made to work, some are better than others, and the next model will be along in 5 minutes
  4. Be very suspicious of much but not all in airport bookshops, especially if it begins with “leadership secrets of Atila the Hun…” or some such stuff.
  5. Leaders exercise power, there is no getting away from it. That must be done ethically and connects public health leadership directly to the competence of ethical stewardship of self, resources and others.
  6. Leadership divorced from values is dangerous. Leadership without clearly understood and examined values is reckless.
  7. An effective style for the varied role of a DPH is emerging in the world of complex organisations, and I call it “adaptive strategic leadership”, about which a little more below.

Conceptualising Domains of public health and leadership – I have updated my 2011 work on Leadership and DsPH with thinking from conversations and discussions and learning events to reflect where I think some of the issues are, and you can find this here http://www.slideshare.net/jamesgmcmanus/leadership-and-ds-ph-update-oct-2014 If it’s useful, use it. If not, discard. Your comments and views would be very elpful.

I have presented these challenges using the occupational psychology concepts of “person-role fit”, “person-organisation-fit”, and “person-system” fit. My own view is many of us DsPH have been struggling to redefine our competencies and skills to be effective when our role, organization and system has changed and the leadership programme currently available have not always been right for us.

Adaptive Strategic Leadership: Conceptualising Leadership Styles – An immense amount of work has been done in the world of leadership research across complex and distributed (geographically or organizationally) systems. After a great deal of reading and reviewing and listening and reflecting it seems to me that leadership style which is adaptive and strategic (see the powerpoint in the link below) is a style which works for the role of senior public health leader in England today. Again, I’ve used the three categories of “person-role fit”, “person-organisation-fit”, and “person-system” fit above as a first way into this challenge.

Based on this work I’ve put forward some hypotheses about DPH leadership styles where I have, I hope, colligated the evidence correctly, but of course have not had either the time or resources to write up the conversations and learning with peers I have done on this, or do some really thorough primary research on this. But for what it’s worth I offer where I have got to so far.

The self-learning powerpoint of this is here http://www.slideshare.net/jamesgmcmanus/doing-the-mix-leadership-mcmanus-shorter

The detailed slides with bibliography on this is here http://www.slideshare.net/jamesgmcmanus/adaptive-strategic-public-health-leadership

And the video of my guest lecture on this is here http://blogs.herts.ac.uk/online-distance-learning/2014/03/17/public-health-guest-lecture/

Finally

I stress that all of this work is essentially “on the way”. I’d love to know what you think. Equally, I’d love to know where you think you have a better way forward

I feel we need a bunch of us to work together on this. My own view is getting this right will move us forward.

Applications of resilience: public health approaches to victims of hate crime

Working with victims from reporting to readjustment

 

I met our victims commissioner for the  Police and Crime Commissioner for the first time last week. He came along to our Public Health Board. He asked why I have a small team in Public Health embedded in our joint police/council community safety unit working on offenders but no mention of victims. And actually he’s right. This is an area we need to do more on.

Back in the day I was at Nacro I wrote a toolkit for the Home Office on hate crime, and another one on homophobic crime especially, working with the amazing Professor Ian Rivers now at Brunel.  Other colleagues worked with me on crime and disabled people. Some of the work I did at Nacro on health and crime is accessible here.

The resource manual Tackling Hate Crime produced by the Association of Chief Police Officers, London. 2000 did some great stuff in its time. But actually we do need to look at this afresh from a public health perspective. What I’ve done here is to summarise where the literature and practice seems to be at from my experience and knowledge. At some point I will try to properly write this up (anyone wanna help? then email me jim dot McManus @ Hertfordshire dot gov dot uk.) But this is offered to help practice.

I’m going to use LGBT hate crime as an example for the rest of this post, but I think there are applications here across all types of hate crime.  I’m not going to focus on bullying in schools because there is quite a lot out there, just check out Ian River’s site or Stonewall  and this post can be read in conjunction with that. Similarly for faith schools there is the work done by the Church of England recently

There are, it seems to me from the growing consensus in literature on hate crime, several public health tasks:

  1. Ensuring the Joint Strategic Needs Assessment accurately reflects community and agency intelligence on hate crime
  2. Defining and finding and encouraging reporting of cases
  3. Ensuring victims are supported effectively in the immediate aftermath, because this will have long term consequences for helping or hindering adjustment
  4. Ensuring consistent standards of practice are in place

The initial approach: seeing victimisation in lifecourse perspective

Working with victims of Hate Crimes is something which, at first sight, can feel awkward and difficult for many. It is easy to assume that because the vcitim is lesbian/gay/bisexual or transgendered that there will be specific issues. While this is often the case, there is usually a core of symptoms and experiences common to victimisation. Some of these can be evidenced by the fact that victims of hate crime may often have symptoms analogous to, or actually experience, Post Traumatic Stress Disorder. There can be significant long term sequelae from experiencing hate crime.

If reporting and response mechanisms, however they are adopted, are to succeed, there is a need to ensure that people who identify themselves as having been victimised are treated and welcomed appropriately and sensitively, and encouraged to make the journey towards resolution. There are, therefore, from a public health perspective short term and long-term goals which anyone working with victims needs to address.

This assumes that there are two roles to supporting victims in the short and long terms, “reporting” and “supporting”.

 

  • Reporting involves making a formal report and commencing the appropriate action to investigate, gather evidence, monitor, etc.
  • Supporting is the process of enabling the victim to make sense of the incident, to seek and offer appropriate help (informally or professionally), to readjust and come to terms with the incident, and rebuild their life.

 

In the immediate term after an incident of victimisation, it is likely that the reporting and supporting process will be provided at the same time, at least initially. This will require appropriate training of those who receive reports.

In the medium to longer term after an incident, it will be necessary to identify carefully whether and when to offer referral on to skilled sources of help, and to offer this sensitively.

Where a report is made by someone a considerable period of time after an incident (e.g. six months or more), there is still a need to ensure that the report is taken sensitively and confidentially, and that appropriate onwards referral for support is offered. This is especially the case where someone has not sought help before. “Flashbacks” to the event, emotional distress and other post-traumatic stress symptoms can often be seen at this point. If the person receiving the report is unsympathetic the person reporting may not seek further help and may present later with more significant emotional distress.

 

Work with rape and sexual assault victims, work with victims of racial hate crime and some projects in existing areas demonstrate some very good practice on work with victims. Lothians and Borders, the Metropolitan Police, Northumbria, Greater Manchester and Hampshire constabularies have all for long periods of time trained police officers to respond appropriately to victims and support them while obtaining necessary reports and statements. Manchester, London, Edinburgh, Hampshire and Lancashire all provide the option of using agencies external to the police where people can report and seek help. Victim Support and Citizens Advice Bureaux both have policies on working with diversity and may be sources of help and suppor. Local lesbian and gay switchboards may also prove useful sources of support, but in some areas are likely to need training to be able to deal fully with these issues.

 

The short-term goals for working with someone who has very recently been victimised or assaulted and is presenting to report the crime or share the experience are:

 

  1. To be able to report the experience and have it taken seriously in a non-judgmental atmosphere
  2. To be listened to without judgment or fear of retribution on moral or legal grounds
  3. To have someone (e.g. a friend or partner) present and treated as a significant other if they wish.
  4. To be assessed for extent of physical, psychological and emotional trauma and supported in seeking appropriate help
  5. To make necessary practical arrangements (e.g. escort home, reporting missing wallet, credit cards, property etc.)
  6. To have an opportunity to tend to personal care and hygiene after any necessary medical or forensic examinations
  7. To be able to feel safe to express or not to express emotional response, as the person chooses
  8. To make arrangements for, and have any dependents informed, should they wish
  9. To be taken seriously.

 

More detail on these goals is written into Table 2 below.

 

These goals could be written into standards and procedures for each agency. Each agency should also assess what training is required for staff and volunteers.

Local Authorities and Police Authorities should consider what issues arise in light of s.17 of the Local Government Act 1998. Local Authorities may need to adopt diversity policies where these do not exist and train staff likely to deal with victims (e.g. housing front-line staff, social services staff, etc.)

The issue of friends and partners needs specific attention. One thing common to both victims of homophobic hate crime and disability hate crime (especially hearing impaired and deaf people) and some faiths is the very strong social relationships. Kinship and family is not just biological. The nature of kinship in the lesbian and gay community alone  is such that friendships can be extremely important relationships[1]. It is important that friends and partners are informed about what is happening and that the victim of crime is able to have them included or not, as s/he wishes.

 

We can actually derive some standards for long-term outcomes of victimisation, which, while in this context written for an LGBT community, are actually pretty applicable across hate crime categories. I’ve adapted these with kind permission of John Wiley & Sons (Chichester) from Evosevich, J.M. and Avriette,M. (2000) The Gay and Lesbian Psychotherapy Treatment Planner. Chichester : John Wiley & Sons. ISBN 0-471-35081-8

 

Long Term Behavioural, Social and Cognitive Goals

 

  1. Physical recovery from trauma/injury and appropriate rehabilitation (e.g. physiotherapy)
  2. Eliminate intrusive thoughts, nightmare and memories
  3. Resume social activities and employment
  4. Increase feelings of confidence and satisfaction with personal identity
  5. Appropriate preparation and support for any court appearances (or restorative justice work) to ensure that the victim does not experience a regression into self-victimisation or other harmful responses to the incident
  6. Enhance personal awareness of safety and ability to protect self
  7. Increase trust in reporting and enforcement systems
  8. Return to the level of emotional and social functioning before the assault.

Suicide and self-harm remains a risk from a public health perspective which needs to be prevented. While from a US perspective, this recent report prvides some valuable insight

 

Using this work

These suggested good practice standards could form the basis of action in any joint work between Police and Crime Commissioner, Public Health and other agencies.

I’ve developed some definitions which could be regarded as standards here using Evosevich and Avriette as a springboard, and synthesising the literature from Ian Rivers and a range of others, to provide what could become a victims response tool for LGBT hate crime, and other hate crime, from a Public HEalth Perspective

There are several sections to this:

  •  getting a clear set of definitions
  • some short term goals which should help the trajectory towards response and readjustment
  • some suggested standards for counsellors/responders

 

 

Table 1 : Behavioural Definitions

This table is intended to help anyone supporting a victim of hate crime to define some of the key problems and issues experienced by the victim.                       

This list can then be used to look at whether people might want referral to psychological or other support, or how serious the experience was.

Number Behavioural Definition of being a Hate Crime Victim
1 Self-report or account by others of physical assault by stranger because of sexual orientation
2 Self-report of being forced to engage in sexual activity with another person
3 Bruises, cuts, abrasions or other trauma
4 Physical pain, wound, disability, fracture or other physical problem requiring treatment
5 Recurrent, intrusive and disturbing thoughts, dreams and memories of assault
6 Blaming victimisation on characteristics of oneself (e.g. being camp, weak because of sexuality, etc.)
7 Restricted range of affect (i.e. reducing or restricting ability to show affection, emotion, etc to friends/family/partners)
8 Prolonged disturbance of mood and affect (e.g. depression, irritability, anxiety, apathy, withdrawal)
9 Avoidance of social activities (e.g., work, activities with partner/friends or family)
10 Subjective sense of numbing, detaching or absence of emotional responsiveness
11 Avoidance of people, places and activities that are reminders of the assault
12 Difficulty sleeping, poor concentration, restlessness

 

Table 2 : Short-Term Objectives in Detail

This table is intended to develop further the short-term goals for the victim identified above both for reporting and supporting agencies. It is adapted, with permission, from Evosevich and Avriette[2].

 

Short-Term Objective for Victim Kind of Intervention from Counsellor or WorkerImportant : some of these interventions need skilled, trained and supervised people
q  Give an accurate and emotionally honest description of the assaultq  Identify and express any guilt, shame, anger, helplessness and/or self-blame associated with the assault q  Actively build the level of trust with the client in individual sessions through consistent eye contact, active listening, unconditional positive regard, and warm acceptance to help increase his/her ability to identify and express feelings.
q  Comply with a comprehensive evidence gathering process (physical, forensic, information, report forms, etc) to assure all relevant evidence is gathered and no serious injuries have been sustained and not diagnosed or treatedq  Report results from physical examination and pursure any medical treatment necessary q  Gather a history of assault including time, location, assailant(s), police involvement, etcq  Assess depression and/or suicidal tendenciesq  Encourage verbal expression and clarification of perception of facts associated with inciden

q  Appropriate referral to medical or dental etc support, and Genito-Urinary Medicine clinic if sexual assault

q  Understand and express how assault has impacted function in social, work and family/partner situationsq  Express an understanding of the psychological impact of the traumaq  Seek reading materials/support groups etc q  Explore feelings associated with the assaultq  Assist victim in identifying the negative impact that the assault has hadq  If appropriately qualified, administer a scale such as the Clinician Administered PTSD Scale (Blake et al, CAPS) or the PTSD Symptom Scale (Foa et al, PSS) to assist with diagnosis and to determine severity of symptoms and impairment. Construct therapeutic goals around this.

q  Support in finding reading materials, support groups, specialist counselling etc.

q  Understand effects of flashback etc reactions to incident and prepare for periodic “rough times” after incident.q  Identify any pattern of blaming self for assaultq  Obtain support from friends, partners and family members

q  End self-blame and place responsibility on perpetrator

q  Challenge negative self-talk and replace with more realistic beliefs

q  Educate about common reactions to assault, e.g. anxiety, flashbacks, avoidance, self-blameq  Help client find coping strategies for when this happens (e.g. friends, relaxation, etc) Identify friends and family members who are supportive.q  Explore solutions for creating support in friends, partner and family members

q  Explore and supportively confront client regarding self-blame and assist in placing responsibility on perpetrator

q  Educate client about challenging unrealistic self-talk and replacing it with realistic self-talk.

q  Assist in exploring restorative justice measures

q  Understand and express how societal homophobia and the perpetrator’s background of hate created the climate for the victimisation, not being gay or lesbian q  Educate client about the nature, incidence and severity of homophobic crime.q  Explore and confront self-blame
q  Be clear on advantages and disadvantages of prosecuting q  Ensure police give support and advice in time up to prosecution, advise getting sympathetic lawyer/advocate
q  Reduce anxiety q  Arrange avoided situations into an anxiety hierarchyq  Develop strategies to deal with these and reduce anxietyq  Practice relaxation and deep breathing techniques
q  List situations, places and people being avoided q  Arrange avoided situations into an anxiety hierarchyq  Develop strategies to deal with these and reduce anxietyq  Encourage discussion about these and confrting them with a supportive friend, partner or family member.
q  Reduce likelihood of future victimisation q  Encourage self-safety strategies (see reporting section of toolkit), attendance at self-defence classes, etc.
q  Challenge irrational fears about being re-victimised q  List situations being avoided and develop self-safety strategyq  Explore sources of fear and develop strategies to deal with this
q  Ensure rational fears about being re-victimised and fed into community safety process q  Reporting to police, community safety forum or through lesbian and gay agency
q  Dealing with problems of faith, religion, etc. q  Ensure availability of sensitive support. The Lesbian and Gay Christian Movement, Quest, Gay Jewish, Muslim and other groups have lists of sensitive and supportive clergy and support groups.
q  Ensure unhelpful coping mechanisms and relapses are dealt with and that more helpful coping mechanisms are found. q  Explore for unhelpful coping mechanisms such as self-blame, relationship avoidance, excessive spending, delusional behaviour, entertaining suicidal thoughts, putting personal safety at risk, etcq  Explore for relapse into any previous risky health behaviours e.g. unsafe sex, excessive alcohol or drug use, smoking, etc.q  Explore for relapse into previously terminated behaviours such as smoking, drugs, etc

 

Life Reconstruction or Deconstruction?

Sometimes a victim of hate crime will enter on a period of re-evaluating their entire life as it currently is. This can sometimes be a constructive process but is equally often a self-destructive and self-blaming reaction to trauma. Skilled support is necessary when this occurs, especially because relationships of all kinds can be severely damaged or terminated during this. At a lower level, any patterns of dependence (on people, possessions, faith or ideas) or addictions (smoking, illegal drugs etc) may be tackled. Sometimes people decide to lose weight or try to change their body appearance, etc. It is important to understand the context of where this is coming from and why. If it is an avoidance response to victimisation, it can block readjustment. If it is a reaction to self-blame or self-hatred, it can become highly destructive. Even if it is a genuine response to things the person feels are wrong (e.g. giving up smoking and losing weight and dealing with an unsatisfactory relationship), taking on too many things in the period after victimisation could have serious consequences for physical, mental and emotional health. Helping the person look realistically at this, encourage development of a “now, sooner, later” plan for their life and encourage getting expert help are all helpful responses to this.

 

Offering Skilled Therapeutic Support

A developing consensus in much of the research and published literature, and particularly in the British Psychological Society guidelines on working therapeutically with LGBT people makes clear that it is not enough for someone to say they are not homophobic in order to work with LGBT victims. Therapists, counsellors and crisis support people working with LGBT people who are victims need to be accepting of the social, cultural and emotional perspectives and issues of the victim. This can raise difficult issues for the worker and for the victim.

We need to consider what support is offered to someone who has been victimised. As can be seen from the goals above this will inevitably involve someone with appropriate skills and experience. It is advisable to consult an agency like PACE (www.pace.org.uk) about standards or the local psychology services. There needs, however, to be some kind of minimum standard to ensure that:

 

  1.  People who are victimised are treated supportively
  2.  Appropriate action is taken to enable the victim to adjust, heal and move on and deal with the perpetrator
  3.  The reputation of the reporting system and enforcement is not tarnished by allegations of poorly skilled staff or, even worse, homophobic or other harmful reactions

For that reason the following principles are offered as some training standards to consider:

 

FOR FIRST REPORTING AGENCIES AND PERSONNEL

 

  • Training in basic issues on homophobia etc as laid down in the training programme in the toolkit
  • Training in reporting procedures
  • Training in first-aid
  • Knowledge and awareness of procedures and sources of help and support
  • Awareness of sexual and mental health issues of victimisation
  • Refresher training annually
  • Availability of skilled supervision and personal support

 

Other Psychological Problems and Issues

There are a range of other problems which can be encountered when doing therapeutic work with the victim of hate crime, from anxiety to multiple loss, relationship issues, sexual dysfunction and family issues.

The American Psychological Association has a good LGBT resource section which provides a range of information and tools.  Equally there are some recent tools on responding to transgender victims of sexual assault which may be helpful.

I do get people asking me about conversion therapy and whether this can help. The developing consensus on this is it can do much more harm than good, and a joint British statement on this from the leading therapeutic and psychological organisations would strongly suggest this is an approach to avoid.

 

 

References

 

[1] McManus,J and Kelly,B (1994) Assessing Kinship Networks. Care Weekly, 1 December.

[2] See also Herek, G. and Gillis, J. (1999) “Psychological Sequelae of Hate Crime Victimisation among Lesbian, Gay and Bisexual Adults.” Journal of Consulting and Clinical Psychology. And McManus, J and Rivers,I (2001) Without Prejudice : A Briefing for Community Safety Partnerships. London : Nacro.

Locating behaviour change in public health practice… some propostions

NICE have recently published their behaviour change guidance http://publications.nice.org.uk/behaviour-change-individual-approaches-ph49 and the British Academy have now released their report on social science interventions in Public Health (press release here http://www.britac.ac.uk/news/news.cfm/newsid/1041  ; report itself here http://www.britac.ac.uk/policy/Health_Inequalities.cfm . )

These two events have come almost simultaneously, and they both highlight the importance contribution of social sciences in health. The British Academy report deliberately focused (as we say in our introduction) on non-individual social science and behavioural science contributions whereas the NICE guidance focuses specifically on behaviour change. These two reports complement each other well and the key issue, as we say in the introduction, is for local areas to find public health strategies which hold population and individual measures, policy/regulatory and behaviour change methods, clinical services and health improvement services in balance. A balanced public health strategy is one which uses appropriate methods and tools for the different facets of the public health challenge we face, especially non-communicable disease.

I’ve read the NICE behaviour change guidance twice now, and I’m using it to bring together our various behaviour change intentions and programmes into a strategy as they recommend. This is a helpful and sane document with wise advice and a good framework for commissioners and providers.

On 28th January Public Health England, NICE and the Local Government Association will be holding Evidence into Practice , the first of a series of events seeking to support the introduction of evidence-based practice.  http://www.local.gov.uk/events/-/journal_content/56/10180/5751863/EVENT

I’m taking part in a panel discussion on the day, and I’ve also recently had colleagues from Public Health England spend a morning with me discusing and sharing how behaviour change approaches fit into a public health strategy.

I believe that there are several big challenges in getting behaviour change working effectively in public health programmes and strategies, and the NICE guidance is an enormous step forward, but we have much more still to do.

1. Having a conceptual framework of where behaviour change fits in public health as part of a strategy is a real challenge and no-one has really articulated this nationally yet in a clear and succinct way.

2. Understanding what method to use- do we target automatic processes or conscious ones, do we do population or individual level?

3. Policymakers often seize on one tool or method because it’s the current buzz topic and attracts a lot of scientific and practitioner interest. That doesn’t always make for  or effective strategy.

4. Many public health departments don’t have expert level behaviour science staff, and often the training we have had relies on models of behaviour change which are no longer used by experts in the field. The field has moved on, our training hasn’t.

4. The field itself is still developing – a bit like public health – and so experts and researchers in the field need to be better at communicating with policymakers

All of this leads me to conclude that we need some propositions about how we as public health practitioners take behaviour change forward.  I intend to share these with participants on 28th January.

Locating behaviour change in public health practice: some propositions

I share this because we ourselves are on the journey of working this out. It needs much more work, but we are already starting to use the framework they help us create.

I: Policymakers and commissioners need a clear Context within which Behaviour Change is used

  • The epidemiology of the UK is such that behavioural sciences can make a significant contribution to primary prevention of non-communicable disease, secondary prevention especially self-management and resilience and tertiary prevention (e.g. coping skills for breathlessness in heart failure.) Behaviour change needs to be seen within this context.
  • This contribution is alongside not instead of policy and population measures (like regulation of tobacco etc). Behaviour change is not the answer to our public health challenges. It is a part of the answer
  • A balanced public health strategy will have interventions at policy, environmental, social, sub-population and individual levels (eg the 6 levels of public health action in the Hertfordshire Public Health Strategy taken from Dettels et al,2009 http://slidesha.re/1e4CVzY ) Another way of looking at this is the Health Impact Pyramid https://www.idph.state.ia.us/adper/common/pdf/healthy_iowans/health_pyramid.pdf

Levels

Example of how they can   be applied –  Tobacco

Social – changing social norms   about health, e.g. acceptability of binge drinking, acceptability of taking   smoking breaks Behavioural economics, social marketing Young people
Biological – immunisation,   vaccinations, treatments Nicotine replacement therapy and cognitive tools for cravings
Environmental – encouraging green   transport, reducing pollution, changing the public realm Environmental cues, display legislationSmokefree playgrounds
Individual Behavioural – helping individuals to   stop smoking Individual and group behavioural change and support
Legislative –  the smoking ban, legislation on alcohol   sales The ban on smokingLegislation on displays
Structural – policy changes such as   workplace health, school health policies Workplace policiesTobacco control partnerships

II: Policymakers need Clarity of the aims and uses for Behaviour Change

  • Behaviour change can be used at population or individual or sub-population levels. Different theories, approaches and methods work for different settings. Policymakers should be aware of this.
  • Including behavioural science skills (e.g. health psychologists) in your service is essential to get it right . They need links with the academics to keep track of the field. We’ve recognised the need for links between public health practice and academic public health starting with our training and running all through our careers. It’s time behaviour sciences had this parity of esteem.
  • Behaviour change can target “automatic” cognitive/emotive processes (e.g. choice architecture and also eye position tracking on cigarette package warnings) or conscious deliberative ones (e.g. behavioural skills to negotiate safer sex.) You need to be clear which you are using for what, and why

III: Policymakers need Clarity of methods, settings and audiences for Behaviour Change

  • The experts in the field need to work with policymakers to create a framework or architecture within which local areas can understand and roll out behaviour change strategies and methods. A preliminary attempt at this is below

IV: A first step at a ready reckoner for behaviour change tools and methods

A   ready reckoner for behaviour change tools and methods

Population   Level

Group   Level

Individual   Levels

“Automatic”

processes

“Conscious” processes

“Automatic”

processes

“Conscious” processes

“Automatic”

processes

“Conscious” processes

Choice Architecture

Advertising e.g. change4 life

Nudge

Groupwork for behaviour

Targeted social marketing

Choice Architecture

Health Trainers

We   still have gaps and weaknesses in science and tools across all of these

(i.e. the science is still developing)

I hope this makes sense, and welcome your comments

What is this personal “resilience” thing and why should we care anyway?

A number of my very patient colleagues have had to endure me banging on about “resilience” recently. Because I hadn’t explained myself brilliantly well, some folk had quite reasonably assumed I was going on about emergency planning or another ‘flu pandemic.

Actually I was talking about resilience as a psychological and behavioural attribute. The things which enable people to appraise and find ways of dealing with things which may cause stress or challenges to their health.

Derek Mowbray, a psychologist working in this field (about whom more later) describes personal resilience as “a process of getting a robust attitude in the face of challenging and threatening events. It’s also about becoming a stronger person as a consequence of facing up to and overcoming challenging experiences.”  He explains in two sentences around 50 years of psychological research.  Those of you with an interest in spirituality will also find strong similarities here in the research which shows spirituality is a strong aid to personal coping, resilience and wellbeing.

But I digress.  The point is, resilience as a psychological construct has evidence around it sufficient to warrant policymakers, practitioners and commissioners taking it seriously as an aid to keeping people as well as possible, and helping them manage their challenges.

Take the field of public mental health, for example. There is growing evidence that neighbourhood stress (poor environment, fear of crime, poor housing etc) adds to the burden on people and becomes a set of vulnerability factors [things which make people more susceptible] to poor mental health. Some recent work on Social Capital in Scotland, for example,http://www.gcph.co.uk/assets/0000/3647/Social_capital_final_2013.pdf reinforces this.

But why should people in health, social care and public health bother?

Well, the research suggests resilience as a construct or attribute can do a number of things for us:

  1. Help people cope with long term conditions and create the behavioural and emotional foundations for good self-care and self-management
  2. Help people cope with life and both prevent some common mental disorders arising and help those living with mental health challenges at low levels to adjust to daily life
  3. Help children and young people grow up well-adjusted and ready for life,
  4. Help people cope with their differences from the rest of society, especially LGBT people finding it difficult to come out
  5. Help carers care for themselves and remain well while caring for others

That sounds like an ambitious agenda, doesn’t it?  But aren’t these outcomes which have been at the core of clinical and public health ambition for ages?

It’s part of my ongoing ambition that behavioural sciences including psychology can help us find models which contribute to achieving these outcomes.

And there is a long research pedigree, which has been around since before the now much vaunted (and valuable) field of positive psychology.

One reading which has had an effect on me is Alex Zautra’s chapter on “Resilience: A new definition of health for people and communities” in pages 3-29 of Reich, et al (2010) Handbook of Adult Resilience http://www.amazon.co.uk/Handbook-Adult-Resilience-John-Reich/dp/146250647X 

They identify that risk factor research (starting with the Framingham Study in 1951 so public health colleagues take note) ” has a long and successful history of identifying biological and psychosocial vulnerabilities to chronic, as well as acute, illness. ”

They ask the question of how people “sustain themselves while ill, and how do so many who are ill recover?” They offer “resilience as an integrative construct that provides an approach to understanding how people and their communities achieve and sustain health and well-being in the face of adversity. Our aim is to define resilience based on current thinking in biopsychosocial disciplines, to outline key research methods employed to study resilience, and to suggest how this approach may further the development of public health and other intervention programs designed to promote health and well-being.”

Since I read this Chapter, I have read probably over 100 other papers which I think underpin the work they do. The challenge for us is operationalize this, to translate this stuff into useable methods and tools which have some evidence behind them, or are promising enough for us to commission and evaluate.

What are the big points in resilience, then?

This field is burgeoning, but here are some key starter points:

  1. Patient, carer and professional need to know that building resilience is a journey. It requires work.
  2. Attitude and outlook on life and your challenges are hugely important, thinking patterns which are not self-limiting, self-destructive or avoidant help you get here
  3. Being able to (i) appraise threats, stressors (potential sources of stress or which test your ability to cope) and daily life, (ii) identify realistically the ability to cope and (iii) identify the strategies you need to deploy to stay well and in control are important
  4. A portfolio of coping skills and techniques (e.g. breathing techniques for people with COPD) for daily challenges is needed, along with the ability to use these to turn daily challenges into routine non-threatening stressors
  5. Non cognitive coping resources (support packages, social support, engagement)
  6. You need some clear steps to take when you’re feeling overwhelmed and steps 3 and 4 aren’t working
  7. You need to know when to ask for help, knowing what help to ask for, and knowing where to go to
  8. You need regular feedback from others (professionals and those in the same situation) on how you’re doing

Now that doesn’t sound too complicated, does it?  There is a good American Psychological Association reading resource and indeed a leaflet on this here http://www.apa.org/helpcenter/road-resilience.aspx

Resilience strategies have been successfully used with people with HIV, people recovering from Stroke and people with drug and alcohol problems for some years. Many of us just probably never called them that and never really used the full range of tools we could to enhance and deliver effectiveness.

And this is just one problem with how we use, misuse, abuse and underuse behavioural sciences in the health and social care system: we don’t really get it right, it’s bitty and incomplete and then we wonder why it isn’t working. We often think we know it and it’s common sense. Behavioural science at its best should be simple, but it’s not always common sense. Behaviour science can be very counter-intuitive. We may, perversely, over-complicate behavioural science, or not pick the right intervention, or get the pathway wrong.

The “what” of what resilience should be in daily life is frequently (unintentionally) sabotaged by how professionals and systems are organized.  But if a public health skill is to identify successful interventions which are evidence-based, and then implement them with fidelity to the evidence, you’d think we should be able to overcome these challenges.

I believe that we often put behavioural science contributions in the too difficult box. If you feel you know it all already then please reconsider, you’re probably missing something.  If you feel it’s too complicated then usually you’ve been reading research that hasn’t translated well out of research into English.

The list of of reasons I’ve just reeled off covers most of the factors where behavioural science approaches haven’t worked well. It’s not the science, it’s how well we use it.

As a way round this, I believe the evidence demonstrates that if we combined behavioural science know-how with practical experience on designing and implementing systems, and getting the right culture to make it work, we could actually make a substantial contribution to the health of people and the workload of our health system. That’s what I want to try to do.

What about resilience for me as a worker/carer/volunteer?

There is an important issue here in what some people call “self-care”. Resilience for those of us working in the challenges posed by our population and our health and social care system is going to become increasingly important if we are to stay the course.

Occupational Psychology has a wealth of learning to offer on how workers who are personally resilient are more effective, efficient, healthier and have better outlooks on life. Having faced some big health challenges recently and taken on a new job, I decided to work my way through Derek Mowbray’s Guide to Personal Resilience. http://www.mas.org.uk/publications/personal-resilience.html 

Ok, Ok, he’s a Chartered Psychologist and you already know I have a bias towards psychology, largely because I am a psychologist by background and because I think there is ample evidence we need to learn more from psychology in health and social policy and the running of public services. But this stuff works.

Mowbray takes you through a questionnaire on your own resilience, and helps you look at things like self-awareness, determination, your vision for what you want to achieve, your organization, relationships, interaction and problem solving and so on. He also gives 18 tips for resilience.

So where next?

I am aiming to get some psychologists and behavioural scientists together with clinicians to look at what we might achieve. If you think you can contribute to this agenda, I’d love to hear from you.