Behavioral Science and Local Empowerment
Here is what is needed to help solve the ebola crisis.
Posted Oct 07, 2014
The West African Ebola crisis is holding up a mirror to the world, and what it is reflecting back is worrisome. I was listening to the news reporting yesterday with a mixture of interest and horror. The horror was not just about what is going on in these West African countries. It was the horror of hearing “How did we let him in?” when the new case in Texas was discussed—as if a virus respects national borders. I wondered if those making their strained comments and asking their anxious questions were ready to follow their own logic to its conclusion. Are we in the modern world ready to quarantine an entire continent out of fear?
“We need to make them change their practices” said an expert, when the burial practices of the local people, including washing and kissing the dead, were discussed. Yes, the practice must change. Touching and kissing the dead is a primary disease vector. But my ears perked up at those two words—“make them.” I couldn’t help but remember that some have seriously suggested sending in the military. My mind presented fleeting images of Marines in moon suits grabbing dead bodies from local people and shoving them into plastic bags to haul them off and burn them. It is a horrifying image alright—one that goes far beyond the horror of the disease.
“We’ve ordered hundreds of thousands of safety suits” intoned another expert. That’s fine so far as it goes, but health workers have literally been attacked and killed in West Africa where local people believe that the workers in moon suits are bringing the disease to the population.
Why are we not asking about the people themselves, and what they want and need?
You don’t have look very hard while watching the news to see both xenophobia and the rigidity and arrogance of western interventionism. You don’t have to listen very hard to hear how fear is overwhelming compassion and perspective taking, while local people are being objectified and de-humanized.
We need another way: An indigenous way that marries local customs and local values with western science. We need a way that respects and trusts the people who are facing this disease head on.
More Than Medical Science Alone Can Offer
I have yet to see a single expert mention that the western scientific interventions needed right now in West Africa go beyond physical and medical science. We need behavioral and evolution science. We need to apply what we know about how the human mind works and how groups function to contain this epidemic.
Contrary to the underlying dogma of force behind goals like making people behave, keeping them out, or shoving them into moon suits—the behavioral science of the mind and the evolution of effective prosocial groups offers a softer, wiser approach that empowers those on the ground. And it may provide better results, more quickly, with less resistance from the indigenous population.
We have a model of how this could work. It exists, right now, on the ground, in one of the hot spots of the epidemic.
Empowering the People
In January 2014 a mental and behavioral health clinic opened in Bo, Sierra Leone, under the name “Commit and Act.” It was the end result of four years of work by a German based NGO begun by psychologist Beate Ebert to bring Acceptance and Commitment Therapy (ACT; it is said as one word, not initials)—an evidence based behavioral approach—to the local people.
Supported by an international team of mental health professionals and by the professional ACT association—the Association for Contextual Behavioral Science (ACBS)—Commit and Act has trained several hundred health care workers, teachers, policemen, religious leaders, nurses, and others since the project began in 2010.
In all of Sierra Leone—a country of 6 million people racked by civil war, poverty, exploitation, and the oppression of women—there was only one psychologist and one retired psychiatrist previously. Commit and Act was filling an enormous vacuum.
Local health care workers were trained in ACT. Local counselors were providing mental and behavioral health services in workshops in Bo, Freetown, and other cities.
The director of the Bo clinic, a local social worker named Hannah Bockarie, became an expert in ACT and attended two ACBS World Conferences.
Internationally known ACT trainers flew to Sierra Leone to provide training. In 2012 and each year thereafter ACBS flew local leaders from Sierra Leone to the World Conference to increase their skills.
How ACT Scales to Social Problems
ACT is supported by more than 100 randomized controlled trials in almost every area of human functioning, from dealing with depression to exercise; from panic disorder to facing the behavioral challenges of cancer. It is a widely applicable model that can be applied to a broad array of human issues.
The core of ACT can stated very simply:
- Make room for difficult thoughts and feelings without entanglement or avoidance.
- Learn to come into the present moment consciously and to attend more flexibly to what is important.
- Link this emotional, cognitive, and attentional flexibility to values-based choices.
- Build these choices out into larger and larger patterns of committed action.
ACT is not hard to scale into social problems. Randomized trials have already shown that it can help reduce prejudice, for example, or heal the wounds of social stigmatization.
But to scale this wok most effectively, ACT needed a social amplifier. It found it in the evolutionary economics of the late Nobel Prize winner, Elinor Ostrom. Ostrom won the 2009 Nobel in economics for her findings that indigenous people can protect their common pooled resources—their forests, rivers, fisheries and so on—and do so very well, thank you, without any government interventionism.
Indigenous people do this most effectively when eight principles are followed. They:
- Define their group.
- Keep costs and benefits to members proportional.
- Foster collective choice.
- Monitor group success and selfish undermining of the group.
- Rein in selfish acts gently with graduated sanctions backed up by more forceful steps.
- Have a conflict resolution process.
- Recognize the right to organize.
- Nest smaller groups into larger groups with distributed power.
When we in the ACT community learned of this, it quickly became clear that the combination of ACT and Ostrom’s principles could be especially powerful. For example, by putting ACT at the front end it was possible to define groups not just by common pool resources, but by shared values and vulnerabilities. By openly sharing values and difficult feelings, the core psychological processes underneath selfishness were easier to see and the defensiveness of quarreling egos could be avoided. By knowing how difficult feelings were mishandled, groups could quickly see what they needed to monitor to achieve faster prosocial action.
It was a marriage made in behavioral science heaven. Two contextual and evolutionarily sensible systems nested, one within the other.
The Evolution Institute (EI) and ACBS threw in together to form PROSOCIAL, a world wide effort to foster prosocial groups using ACT and Ostrom’s design principles.
Supported by small grants, a manual for PROSOCIAL trainers was hammered out by an expert team of evolutionists and ACT researchers. We created a training model where groups would walk though ACT processes, first individually investigating questions like: What do you deeply care about? What feelings or thoughts tend to get in the way? How does that avoidance or entanglement manifest itself? If you could move toward your values, what would it look like in the world of action? Then they expanded this investigation to apply to the whole group: What do WE care about? And so on.
Groups were also taught to review the Ostrom design principles—studying their collective choices, identifying what they needed to monitor, exploring how they could confront selfishness and ensure proportionate costs and benefits, and so on—to function more effectively.
It is this marriage between ACT and PROSOCIAL that has been so effective in helping to manage the Ebola crisis in Sierra Leone.
How ACT and PROSOCIAL Models Have Influenced Ebola
Commit and Act became interested early on in PROSOCIAL, and with the outbreak of Ebola, Hannah started to use ACT and PROSOCIAL to educate the population about the disease, empower them to make choices, and develop healthy behavioral alternatives. Because of the impact of her work Hannah was named the leader of Ebola prevention in the Bo area, one of 13 districts in Sierra Leone, by the Ministry of Health and Sanitation.
In my previous blog, Kissing the Banana Trunk, I told the story of how groups in Sierra Leone have come up with local solutions that no western outsider would ever have thought of, such as burning the dead but performing cleansing and burial rituals with a banana trunk. This ground up approach has proved tremendously effective in helping to alter behaviors like burial customs that were proving difficult to change “by force.”
The approach of empowerment and kindness instead of top-down interventionism is key in other ways. Last week the District Health Management Team in Bo brought a man into isolation who was suspected of having Ebola. He refused to be tested and became violent. He was terrified. The Ebola Emergency Operations Team asked Hannah to have an ACT counseling session with him.
Conducting the session wearing personal protective equipment, she used ACT to help the man link his personal values to what he was being asked to do, even though it was frightening. He gave his consent and cooperated with the blood test, without further risk to himself or the staff. The entire District team learned a valuable lesson.
Yes, he could have been forced through the process—but values-based empowerment was a far more humane and caring path and as a result this man is now getting both the medical and psychological support he needs.
This same process can scale. Just yesterday we received the infection data for Sierra Leone for the last three weeks. The Bo district went from the fifth most infected district in the Sierra Leone area to the seventh. Only 13 new cases of Ebola have been diagnosed in Bo over the last week (from 83 up to 96 cases)—that’s a 15.6% rate of increase, the ninth lowest increase in the 13 districts, two of which had essentially no infections to begin with.
It appears that the combination of ACT and Ostrom’s principles is working.
PROSOCIAL is very efficient in changing behavior quickly, a crucial factor in the current situation. It also improves the willingness of suspected cases to get tested. Meanwhile ACT counselors are providing psychological support for individuals, families and communities who are quarantined or who have lost family members. And they are helping to take care of Ebola orphans.
There is a set of lessons to be learned in this experience. Success in the modern world cannot be based on physical and medical science alone. We need policies that are informed by behavioral and evolutionary science. We live in one world and our survival depends on us learning to live together. When we look to behavioral science we see an alternative to the ego-based policies of “I know best.” Force and rigid, top-down governmental interventionism is not the solution, especially inside a crisis, because buy-in is essential for success. We need to empower the local people.
Western behavioral science and local traditions and customs can go together to do just that, resulting in more profound and more rapid behavioral change. But that will only happen at the level needed to transform this crisis if the policy makers listen. We have a living example on the ground in West Africa. It is time to learn the lessons it provides.
If you want to learn more about Commit and Act or donate to their cause, you can do so at their website: http://www.commitandact.com/commit_and_act.com/home_engl..html