Guest Post by Yen Chai Chen, BCBA (yenchai.chin@gmail.com)
SingHealth Centre for Population Health Research and Implementation
LinkedIn: https://www.linkedin.com/in/yenchaichin/
Selectionist Blog: https://selectionist.substack.com/
Yen Chai Chen writes the excellent blog, Selectionist, which can be accessed over at Substack. His goal is to explain behavior to people who aren’t behavior analysts, and he communicates clearly about complicated issues, as you can see in these sample posts: Living for the Moment and Discounting the Future; They Not Like Us; and What’s in a Nudge? This is the second installment of his two-part discussion about his efforts to bring a behavioral perspective to a multidisciplinary government public health institute.
In Part 1, I made a case for venturing beyond applied behaviour analysis’ traditional boundaries. Here in Part 2, I share some of my experiences operating in one such environment and lessons I’ve learnt in working effectively here.
First of all, much has been written on collaboration between behaviour analysts and other professionals (including here and here). While framed for the clinical context, they contain important lessons that are broadly applicable in all interprofessional collaborations, which I won’t rehash today.
Instead, I’m offering a more descriptive, contingency-shaped account of what has worked in my particular context—as a population health and implementation science researcher and the sole behaviour analyst in my centre.1
Some Properties of Strange Waters
Venturing into these strange waters comes with some unique challenges:
- I operate within theoretical and operational frameworks unfamiliar to most behaviour analysts.
In healthcare, the medical lens dominates. Recipients are patients; prevention, treatment, and management of diseases are front and centre of how people think (though that is starting to shift). Programme effectiveness is evaluated based on health outcomes. Where the behavioural sciences are concerned, behavioural theories (with a small ‘t’), models, and frameworks such as COM-B/Behaviour Change Wheel, Theoretical Domains Framework, and Health Belief Model are commonly used. Heard of them? Neither had I.2
- I wrestle with problems beyond the scope of my behaviour analytic training.
My work spans diabetes, frailty, ageing-in-place, medication adherence, and the built environment-health relationship. All these areas are ripe for behaviour analytic enquiry. To give an example: Of course, the built environment influences health. Its design influences our physical activity levels, what we eat, how we spend our leisure time, and so forth. The width of roads and footpaths influences how much walking vs. driving we do. The ambient temperature and accessibility of green and blue spaces impacts how much time we spend outdoors. Behaviour analysts rarely engage in these areas of work (for some exceptions, see, e.g., here and here), particularly at the population level. When we do, it’s also quite often in isolation from the broader scientific community.
- My skill sets as a behaviour analyst are not well understood or utilised.
As a behaviour analyst, we are keenly attuned to the functional relationships between the environment and behaviour. However, population health research typically looks at the relationships between exposures/predictors (e.g., mHealth intervention) and health outcomes (HbA1c levels). As any behaviour analyst knows, many of these improvements come through changes in behaviours, but the behaviours themselves, and mechanisms of behaviour change, are rarely evaluated.
In such strange waters, I have found it hard to unlock my value. And dare I say, sometimes I find it hard to even know what my value is. And yet, when one is thrown into the deep end (voluntarily so, in my case), sometimes the strong selection pressures bring about great adaptations.
Navigating Strange Waters
I’ve distilled some key lessons from my experiences, organised by whose behaviours we’re looking to change:
1. Learn, learn, learn (changing our own behaviours)
A blasé point, you’re probably thinking, changes in circumstances will of course occasion learning. But I think this learning can be accelerated and better directed if we bear a few things in mind.
Yes, I said mind, which brings me to the first lesson—we should learn about how others view and talk about phenomena. There’s simply no way of collaborating effectively otherwise. It is ok to speak French, even if deep down we believe English to be the most beautiful language. Also, speaking French won’t rob us of our ability to speak English.
The second lesson is, we should do so from a position of genuine curiosity and epistemic humility. No single discipline has a monopoly on the truth.3 I’ve laid the case for adopting this attitude in Part 1, but to give a more concrete example, in my opinion, the field of implementation science, which looks at the broader systematic factors surrounding the systemic uptake of interventions, has much to offer in teaching us about intervention sustainability and scalability. I’m glad some of our colleagues have started to take note of its potential contributions to our field. Here are two examples of widely used implementation science models: Consolidated Framework for Implementation Research and RE-AIM.4
We should recognise that when dealing with wicked problems, our behavioural lens often allows us to see only parts of the problem. Solving such problems requires integrating knowledge from multiple disciplines, even producing new knowledge that transcends individual disciplines. The better we understand the knowledge from other disciplines, the better our chances of pulling off a successful integration, and solving the problems we hope to solve.5
2. Shape, shape, shape (changing the behaviours of others)
Shaping is one of the greatest treasures in the behaviour analyst’s toolkit. The true value of shaping is, in my opinion, that it helps calibrate our own focus from binary (right/wrong) and fixed outcomes, to continual and adaptive processes.
Shaping requires patience and dogged persistence. As applied to changing complex repertoires of behaviour, it is also both a science and an art—the process is not formulaic, but requires skilful application.
I have found that the 4 guiding principles of motivational interviewing to be incredibly helpful in effective shaping.6 Here is how I applied them in my context:
- Express empathy: Accept the validity of differing viewpoints. As a wise person once said, the organism is always right. Everyone’s perspectives are shaped by their disciplines’ pressures, perspectives, and constraints.
- Develop discrepancy: Encourage reflection on conceptual or methodological gaps in reaching our shared goals. Adaptation comes from recognising one is in a state of misadaptation.
- Roll with resistance: Anticipate resistance, redirect and realign when encountering it. Resistance is a feature, not a bug in figuring out how to align efforts towards a superordinate goal.
- Support self-efficacy: Reinforce change, and the belief in one’s capacity for change. Shaping will result in many small wins, and each should be celebrated wholeheartedly.
On the other hand, preaching is quite often inversely correlated with changing minds. At best, it results in sympathetic smiles. Instead, I’ve achieved much success by adhering to the maxim show, don’t tell.
Conclusion
The lessons I’ve shared today are non-exhaustive, and perhaps quite rudimentary, but should serve as a rough guidepost for those of you interested in acting to save the world. As more of us step forth and contribute toward solving wicked problems, I look forward to learning from your own experiences and actions shaped by your own unique contexts.
Footnotes
- In fact, as far as I’m aware, I’m the sole behaviour analyst in my organisation, the largest healthcare group in Singapore, with >30,000 employees. This speaks to the bridges we still need to cross to have the societal impact our forefathers envisioned.
- Which is some sort of a tragicomedy, given than the COM-B/Behaviour Change Wheel paper, published in 2011, has amassed close to 15,000 citations, almost double of our venerated Some Current Dimensions.
- From a philosophical pragmatism standpoint, the truth is found in what works, and what continues to work. One might argue that for many socially important problems, behaviour analysis hasn’t really “worked.”
- We should also learn to make better visuals like these. This should go some way in resolving our image problem.
- I wrote an article about this recently.
- For those interested, Christopher and Dougher (2009) provide a behaviour analytic account of motivational interviewing.