What is mindfulness and why should we be paying attention to it in our individual and organizational work in health systems? As the calendars change and we begin to reflect on the year past and what is to come, it seemed like a good time to ask that question.
Shifts in the calendar are always strange and wonderful events for me. On one hand, it seems that the world has changed with new possibilities, (literally) new calendars and date stamps on everything, and what seems to be a wave of renewal and energy among friends and family. It is the time when people make resolutions and aspirations to make the world and their part of it a better place. As I’ve written before, this is not unproblematic and often leads to failure, but the act of reflection is one of the consistent benefits regardless of whether goals are achieved or not.
Mindfulness, an intentional act of paying active attention to the present moment in a non-judgemental manner, has been found to produce benefits for individuals and organizations alike. University of Toronto professor and psychoanalyst Scott Bishop and others have sought to take the idea of mindfulness further by looking at what this act of paying attention really is and how it could benefit human wellbeing. In their 2006 paper, Bishop and his colleagues reviewed the state of the literature on mindfulness-based approaches to health and wellbeing and convened meetings with those doing research in this are with an aim to come up with a more specific definition of mindfulness suitable for research.
To that end, they came up with the following:
We propose a two-component model of mindfulness. The first component involves the self-regulation of attention so that it is maintained on immediate experience, thereby allowing for increased recognition of mental events in the present moment. The second component involves adopting a particular orientation toward one’s experiences in the present moment, an orientation that is characterized by curiosity, openness, and acceptance.
This model has some critical features worth expanding upon, particularly for those of us working on issues of health.
1. Self-regulation of attention. Unlike a traditional marketing approaches that seek to capture our attention and dictate things to us, self-regulation implies some sense of resistance to the messages that come or are thrown up at us (think: Times Square for the most extreme example of this) and control. It is tied in with self-determination theory and many other health behaviour change theories that stress the importance of having self-directed influence over our cognitions and emotions rather than having them unduly, mindlessly, influencing us. It sounds simple, but it isn’t easy when you’re bombarded by media messages.
2. Maintaining focus on the immediate experience and the present moment. Here I turn to sage wisdom of Yoda in his conversation with Luke Skywalker and Obi Wan Kenobi about the problems Luke has with sustained attention on the present, rather than fantasizing about the future.
A Jedi must have the deepest commitment, the most serious mind. This one a long time have I watched. All his life has he looked away… to the future, to the horizon. Never his mind on where he was. What he was doing. Adventure. Excitement. A Jedi craves not these things. You are reckless.
Jon Kabat Zinn has written and spoken extensively on this problem of sustained attention on problems and how our attentive resources tend to focus on almost anything but the present moment. Just spend a moment paying attention to where your mind is right now and it is probably not fully in the present.
3. Encourage curiosity, openness, and acceptance. These three points, joined together, are ones that are near and dear to my heart because they are so poorly done within my world of public health research and practice, despite what it may appear. Curiosity means supporting innovation — translating knowledge into actionable products that have transformative value (that is, it changes the way you see, act and engage with things – including ideas) – is something spoken of widely, but rarely achieved. Funders, researchers, policy makers and politicians alike are all becoming more risk averse it seems and that is almost antithetical to curiosity, which necessarily means going into the unknown.
And acceptance builds on the other two, drawing us to consider the value in new ideas and perspectives that differ from ours. It means attention to diversity and a welcoming of difference. That kind of thinking however, steers us into the realm of complexity, where the idea of best practice (a concept that seeks to reduce difference) is inappropriate in favour of good or appropriate practice.
Becoming mindful enables us to attend to the complexity of human systems and can guide our thoughts and actions in a manner more aligned with our purpose for doing what we do in the first place. It is that re-alignment of purpose and the desire to understand what we’ve done in light of what we desire that prompts such attention to New Year’s resolutions this time of year. A more mindful take on this suggests that we may wish to consider doing this much more than just at the end of December and beginning of January. Imagine what we might do then?
Happy Mindful New Year!
The holiday season now takes a shift away from the goodies and rich foods that start with Hanukah and (almost) end with Christmas. There’s one last big day left*: New Years Eve/ Day.
* In Canada, Australia, New Zealand and the UK we have Boxing Day today, the day when all the unsold merchandise for Christmas goes on sale and people do silly things like camp out overnight on Christmas Night so they can get a deal the next morning. It’s just like Black Friday in the US.
People often wake from the sugar-induced near-comtose generated by all the treats on Boxing Day to realize that their new holiday pants fit tighter than expected, that the number of wine bottles in the recycling are hard to count, and that the return to everyday life that comes after the holidays might not be as jolly given the absence of any holidays to look forward to. Add to that the myriad “year in review” lists and recaps on television, print and the Internet and its quite natural to want to make a New Year’s Resolution.
The answer to that is: don’t do it. They don’t work and the whole thing is one big fallacy.
But evidence never stopped people from doing things before — even physicians and scientists — so if you must make them, here are some recommendations from a person that teaches a graduate level health behaviour change course on how to be a little smarter about goal setting:
1. Be specific. Declaring that you’re going to be healthier in 2011 isn’t providing much to go on. Does that mean that you’re going to eat better? And if so, what does that mean? A big mistake is that people keep their goals too general and thus, never really know if they’ve acheived them. One rubric to use is the S.M.A.R.T system for goals. S.M.A.R.T. refers to goals that are Specific, Measurable, Achievable, Realistic and Time Framed. The closer you can adhere to these, the more likely you are to achieve them.
2. Keep quiet. There is a school of thought that suggests that advertising your goals to the world (make them public) is a strong way to motivate change. The thinking here is based on theories of social norming and pressure that suggest that the fear of letting others down will motivate you to succeed. That might have some currency, but it paradoxically fails for reasons that have little to do with others and much to do with our brain. Research from NYU psychologist Peter M. Gollwitzer and his colleagues (PDF) found:
When other people take notice of one’s identity-relevant behavioral intentions, one’s performance of the intended behaviors is compromised. This effect occurs both when the intentions are experimenter supplied and when they are self-generated, and is observed in both immediate performance and performance measured over a period of 1 week. It does not emerge when people are not committed to the superordinate identity goal.(p.616)
Some other resources on this are available here. This isn’t to say that you can’t share aspirations with people, but when you declare you’re going to do something out loud ( following S.M.A.R.T) and get feedback from others, your brain starts to imagine that you’ve already accomplished the goal and is already diminishing your motivational fire.
3. Do it for yourself. Another reason these publicly stated goals might cause problems is that often we announce goals that we want to believe in (or believe others approve of), rather than those we want for ourselves. A large body of evidence suggests that we’re much more likely to do things that fit with our self-concept and values than those that challenge or complicate it. Self-determination theory is the foundation for this concept. Author Daniel Pink wrote an accessible piece on this in his recent book Drive. This can be applied broadly or more specifically. For example, with regards to weight loss, there are a lot of options to assist that from changing the food you eat and the way you eat (not dieting, which is a far larger fallacy than New Years Resolutions and persists even more) to exercise. Perhaps running on a treadmill is something that bores you to tears, so try a group dance class instead. If you’re not a fan of salads, try doing more with beans, oatmeal, nuts, fruit or smoothies. There are lots of ways to get the same place, but choose the things that you really like first.
4. Be social and connect. Even if you’re not announcing your goals to the world on YouTube or doing all the things you want to do first, it is still important to be social. Research on social networks and health show remarkable links (pun intended) between our social networks and our health behaviours. Smoking, obesity and mental health are all enhanced by having strong social networks (however you connect — this isn’t just about Facebook or Twitter). Building strong connections with people can offer so much benefit in terms of keeping you healthy, informed and “human”.
5. Help yourself by helping others. If you want to reach your goals, try helping others reach theirs. Working with your friends and family to support them in reaching their goals can actually strengthen your own resolve. Communities of practice are groups of individuals that are motivated to support each other in solving particular problems that often fall outside of traditional lines of work, discipline or problem domain. These collectives are often self-organized and volunteer-oriented and because of that, they capitalize on many of the aforementioned points. Find a community of people tackling the same problems and offer your assistance and wisdom. In doing so, you might find that you start to work through your own challenges and issues. Research on complex systems shows that small, incremental changes over a long time will produce much more stable change than radical upheavals at once.
New Year’s resolutions are problems because they often set us up for failure. Perhaps the one resolution that you will want to follow this year is to skip the resolution altogether and commit to doing something small often and enjoying yourself and those around you while you do it.
I teach a course in health behaviour change and one in systems thinking perspectives on public health. Both courses complement each other and both deal with change. However, most of the major theories of behaviour change deal with the subject in a straightforward, linear manner. Models and theories like the Health Belief Model, Theory of Reasoned Action, and Social Cognitive Theory all have elements explicit or implicit to them that suggest change occurs in a largely linear manner from problem state to desired state.
One of the more popular models of change is the Transtheoretical Model, which included the concept of Stages of Change. Developed by James Prochaska and colleagues at the University of Rhode Island (and others), the model has become widely popular and used all over the world to guide change efforts. The problem is that the evidence for its effectiveness, despite the logic it brings with it, is weak.
Robert West, the editor of the journal Addiction, and others, issued a rather stinging set of criticisms against the Transtheoretical Model’s Stages of Change concept, pointing to the evidence that suggests that as many (if not more) people quit smoking or behaviors like that with no apparent plan in place. “It just happened” .
Indeed, the data suggests that Stages of Change is not that strong as a predictor of eventual change, yet its popularity suggests something that goes beyond evidence. At its root is the idea of “ready, set, go” and taps into our deep-seated interests in making plans and moving ahead in a straightforward manner. In short, it fits linear thinking to a tee.
Over time, proponents of the Stages of Change theory and related models and theories have asserted that people do move forwards and backwards through the stages and that it is not simply a one-way view of change, but in both cases the end is still some form of linear trajectory.
What makes behaviour change theories like the TTM and others problematic from the perspective of complexity is that they are linear. Yet, linearity is the way we define the problems in the first place. These theories are all based on some form of cognitive-rational foundation that take at its core the idea that information is the starting point for change and that the way information is perceived and worked through will serve as a touchpoint for further motivational activities.
What is embedded within this assumption is the idea that, once configured, information is organized in a relatively stable, consistent manner. What it does not do is account for the ways in which our memories, circumstance, situation, and the addition of new information can only only change what we know, but also the way in which we know it. Thus, recombination of information leads to new insights and activities, not all of which are necessarily in support of the trajectory that was initiated.
Richard Resincow and Scott Page start to probe some of this terrain in their article published a couple of years ago looking at quantum change. The article, which was widely discussed, challenges the very notion that the approach we take to behaviour change is misaligned with much of what we know about complex adaptive systems. And to this end, the human mind and body is indeed a complex adaptive system in many respects. Certainly our social worlds fit this description.
If this is the case, and we take this idea that recombination of information can and does occur, it has profound implications for how we develop social institutions and the way in which we support individuals looking to make changes. It means not expecting that changes will stay in place, but rather always anticipating the possibility that something might shift and dramatic transformations could occur.
Flexible strategies, adaptive strategies and those that attend to context and the constant, dynamic flow of information are those that will provide more useful models for change in this worldview. It might now repudiate the models we use now, but it certainly casts new light on the directionality of change that they invoke. And in simply shifting those arrows around, we open possibility for understanding change in a wider way that might eventually lead us to one that takes complexity into account more fully, and learning.
Simple, straightforward and predictable things are pretty boring, but they at least can be understood without much effort. And sometimes that simplicity provides comfort that we can’t find in complicated, complex or chaotic events. As we find ourselves working long hours eating badly and sleeping less hours than our body would like its no surprise that we find a lot of organizations trying to make complex change using simple processes (that won’t work). It’s tiring thinking about complexity and simplicity is, well, simple. We don’t need to consider the pushback that could come from making our morning coffee, we need not worry about the unintended consequences of ironing our shirts, or contemplate the emergent patterns that come from picking a green M&M out of the holiday party bowl over the red one. After a long day at the office or an emotional conversation with a loved one, these ‘simple pleasures’ as they are often referred to provide us comfort that can’t be found in complexity.
But change is rarely a pleasure, but always an adventure; When it comes we need to be ready and have the energy to tackle it.
It is perhaps for that reason that people try to deny it or over-simplify problems. Its the very reason why the self-help book section of a store is so big, why New Year’s resolutions are so popular (do you have yours yet?), and why late night infomercials and daytime talkshows still persist in their efforts to sell us the quick and easy change. Change your life in three, five, seven, 10 or 12 easy steps!
It is never that easy. If it was, I could teach my students health behaviour change in an evening seminar at a hotel airport instead of a semester-long graduate course that is, at best, showing the ice floating above the waterline. However, in that proverbial sea of self-help resources one of the few ideas that stands out comes from The Power of Full Engagement. In the book, authors Jim Loehr and and Tony Schwartz point out that a key to change is managing energy as much as it is our cognitions, emotions and behaviour. It is the energy we bring to situations that is the necessary precondition to becoming fully engaged and able to change. It’s why its so hard to pay attention in class or a meeting when you’re tired. Or why you tune out when the message itself is tired; the same old stuff trotted out again and again.
Change in human systems is complex.
Tired individuals and organizations tend to opt for those solutions to complex problems that are simple and, as H.L. Menken said, wrong, — see my last post. Ever seen profound change take root in an exhausted environment? Not me. It’s one of the reasons why effective leaders are those that aim to spark emotion and raise the energy level of those that follow them as much as instill new ideas. Indeed, if you look at many of the best leaders out there, they tend to create environments where new ideas come from introducing new ways to see the complex and make it exciting. A terrific example of this is Benjamin Zander’s talk at TED looking at how the complicated structure and complexity of classical music can enliven the spirit.
So perhaps our first strategy to change is to take a nap, play some Chopin and watch an inspirational movie than try and solve it otherwise we might end up with simple and wrong solutions to complex problems and be no better off for it.
Yesterday I had the privilege of speaking to Cancer Care Ontario‘s LEARN community of practice meeting in Toronto about social media and how it could be used to support their health promotion (specifically tobacco control) work with youth and young adults. This group does a lot of work with young adults so information technologies are not alien to them (indeed, many had blogs, Facebook pages and other social media tools), yet they were still uncertain about how best to use these tools and why they might want to in the first place. In preparing for the presentation and in the subsequent discussion afterwards I had this overwhelming sense of having been here (and there) before. It was, as Yogi Berra famously said: deja vu all over again.
My first study on the Internet was conducted in 1995, a time when the World Wide Web was just becoming known outside of academia and the best option for social support was UseNet groups. With a friend of mine, we did the first (to my knowledge) global survey on the use of the Internet for social support (note: this is why its important to publish your results as soon as you get them, otherwise it will never happen . I did, however, present findings at the Prairie Undergraduate Research Conference at the University of Winnipeg, perhaps the most remarkable event in support of student scholarship in psychology (or any other discipline) I’ve witnessed. But I digress…)
As I moved along in my career, I continued to work with the Internet as a tool — from discussion boards to interactive smoking cessation support tools and using qualitative methods and design principles to large randomized trials. All along I would hear (and still do) comments like “isn’t that (technology) stuff just for fun?” or “why would anyone want to use that?” .
The same pattern keeps repeating. 20 years ago if you were to describe using email as a serious means of communicating – something that one should devote work time to – most employers would scoff. Now, email is integrated deeply into the very fabric of nearly every knowledge-based enterprise to the point that the corporate market for mobile services to deliver email to its workforce is in likely in the billions. 10 years ago if you were found in your office searching the World Wide Web for content of a serious (i.e., work-related) nature, a similar scoff might come. Now? Open access journals are becoming top publishing venues in their field (see the Journal of Medical Internet Research in the Health Services Research area as one example) and tools like Google Scholar are invaluable resources for scientists and practitioners alike. The LEARN group gets this. They are the ones who are trying things out and trying to push the boundaries of their organizations, changing mindsets and considering whether or not social media is for them or not and in what measure.
A few months ago I spoke to another, similar group of health practitioners about eHealth and asked the audience about their experience using social media. Many of these settings — particularly public health units — didn’t allow Facebook or YouTube to be accessed. Presumably, it was to avoid people doing things that weren’t serious work. This all reflects a mindset pattern that repeats in many organizations — public health or otherwise: people don’t see how the new technology can help because it is not obvious (or they haven’t even tried it), therefore it is dismissed as irrelevant or even banned outright.
The challenge here — and one that I take up — is about lowering these barriers through education. I think it is imperative that those of us (perhaps you, dear reader) who work in social media and eHealth help others to support their efforts to change the culture of their organizations. The LEARN folk are doing this, just as I did so with them. No matter how much we as ‘experts’ like to showcase new tools, we are the early adopters and massive social change will not happen until we inspire the next wave of people to take it up. One forum for this is at the eHealth Promotion social network, a Ning group formed out of the experiences at this year’s Health Promotion Summer School in Toronto, that was on the very topic of teaching people about eHealth in public health. Best of all, when we get these new adopters joining into the discussion and familiar with the tools, they can also help us determine what doesn’t work with these tools, what their limits are, and even what risks they bring in a manner that is informed, constructive and not dismissive.
If public health is going to be innovative, that is doing things that haven’t been done or in new ways to address emerging problems, then it needs to understand social media. What and how much it adopts it is really a matter of need and circumstance, but as I pointed out in my talk yesterday, we cannot wait for the evidence to come in to make that leap. Last year, the research on Web-Assisted Tobacco Interventions (perhaps the leading domain of public eHealth research) finally reached a point where we could say with some confidence that the principal of using the Web to support smoking cessation and prevention is evidence-based. That was more than 15 years after the birth of WWW.
Are we going to have to wait another 15 years before public health widely adopts tools like microblogging (e.g. Twitter) or considers the use of mobile messaging and video or social networks in its work? By then the evidence might be in and if that is what it takes to get this adopted or accepted it will be deja vu all over again, and that’s not a good thing.
It’s been a busy week and one that has focused on means and ends and provided me with many examples of how those two things get confused and become de-linked.
I started the week off in Vancouver with meetings focused on my ongoing research looking at collaboration and outcomes associated with the study and evaluation of the Life Sciences Institute at the University of British Colombia. Our research is trying to ascertain the means from the ends — and even what those ends are or should be. Does increasing interaction between scientists of different disciplines produce more research? better research? different research? and if so, is this a factor of the people?, the setting?, facilitators within the LSI and outside?, something else? or some combination? It’s the kind of problem that makes researchers squirm or jump (thankfully, I’m in the latter).
These kinds of means and ends are important for not only research, but understanding innovation in practice and creating better strategies to facilitate that. Nowhere was that more clear than in the two days of presentations and discussion at Medicine 2.0, perhaps the most important gathering of people — researchers, clinicians, decision makers, patients and advocates — interested in learning more about how collaborative e-tools brings about change. Events like these are dangerous; for those in eHealth and those outside it.
For those outside, the danger comes from having a group of innovators share with the world how ‘Web 2.0′ tools can facilitate self-organization, community engagement, and patient involvement in ways that challenge the status quo quickly and with tremendous force. As I tell my students in my Health Behaviour Change course at the U of T : the only people who truly welcome change are wet babies.
Take the eHealth Ontario debacle, which continues to roll along. It now has come to the attention of the public that Ontario already has an eHealth record system linking close to 100 facilities only it is focused solely on child health (i.e., those under the age of 19), when its spent millions on developing a completely new one, presumably for the other part of the population (?). What is required here is changing the tools to address a larger population, but more importantly, changing a mindset that there needs to be new tools, rather than adapting existing ones. The means (a centralized database for health records in this case) is confused with the end (a healthier province & a more efficient and effective health care system). A quest for getting the ‘right’ means or getting a particular ‘means’ is delaying our ability to move towards the healthy end.
From the inside eHealth, these kinds of events are dangerous for reasons that are not that different than those of outsiders. In this case, there is a tendency to focus on the means without consideration of the environment in which those methods are deployed. At Medicine 2.0 there were talks ranging from a focus on patient support needs and portals, public health support strategies, wiki-based clinical practice guidelines, and a variety of ways to engage various audiences with tools like Facebook and Twitter. In nearly every presentation the focus was on the novel ways in which technology could facilitating change. Yet in the audience and at the breaks these presenters (myself included) found ourselves talking less about the tools, but the organizational cultures and shifts that need to take place to make these tools work. Indeed, the tools can do a lot, but without an organizational mindshift within our health and public health systems, even the most innovative, responsive and affordable tools will not truly make the change that is espoused.
We are clear on our end, now its time to reconsider our means in light of the tools and the culture that exists around them.