the community
Haruv Award Lecture
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Stickiness Is an Empirical Pursuit: The Case for Reframing Child Mental Health Susan Nall Bales FrameWorks Institute
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veryone wants his or her issue to be sticky these days—to be talked about, get into the news, get in front of influential people, and so forth. However, the concept of stickiness, as put forward by scholars Chip and Dan Heath, is more than a fancy new term for salience. Rather, stickiness is defined in a way that recognizes the last several decades of research in the cognitive and social sciences on how people think about complex social issues. It poses appropriate goals for communicating issues that include the ability of a communication to convey the idea that the communicator intended, its innate resistance to default thinking, its redirective power, and its ability to bounce back even when the conversation degrades. In sum, authentic stickiness means more than getting an issue in the news; it means understanding and controlling the cognitive effects of such stories. The Heaths provide an elegant recipe for achieving stickiness. The starting place is the identification of the central message or finding the core. Communicators must then figure out what is counterintuitive about the message. In other
words, why isn’t the message being communicated naturally? The message must be communicated in a way that breaks the guessing machines (ways of thinking and understanding) of members of the audience. Finally, once the guessing machines have failed, audience members must be helped to refine their “machines.” In this article, we argue that stickiness is an empirical pursuit, one that requires an accretion of methods from across the cognitive and social sciences but which, if pursued systematically, can contribute significantly to public understanding. Drawing from the FrameWorks Institute’s development of Strategic Frame Analysis, we demonstrate how our methods can be used to pursue stickiness and with what effects. Applying this approach to the issue of child mental health, we demonstrate why approaches that posit resonance or salience are likely to prove ineffective in helping the public to prioritize prevention and treatment for child mental illness or promotion of child mental health. According to our research, how the public understands or “models” child mental health poses a considerable roadblock to engagement and policy support.
We make these claims based on more than 5 years of qualitative and quantitative research conducted in the United States and Canada on how people think about child mental health. Beginning in 2008, as part of a partnership with the Center on the Developing Child at Harvard University and with support from the Endowment for Health (NH), researchers at the FrameWorks Institute designed and conducted a series of studies that roughly parallel the process suggested by the Heaths. Following the reports and recommendations that emanated from this foundational inquiry, additional research has been conducted in Alberta, Canada, and in Jacksonville, FL, to further verify the initial findings and retest recommendations in these divergent locales. The FrameWorks Institute’s research base on child mental health alone comprises more than 12,000 informants and includes reviews of 4,000 news and scholarly articles. It is from this multimethod database that we draw to explore the challenge of making child mental health a stickier topic in public thinking.
This article is based on the inaugural Haruv Lecture presented at the Fifth Greenville Family Symposium (sponsored by the American Orthopsychiatric Association, the Clemson University Institute on Family and Neighborhood Life, the Haruv Institute, the International Family Therapy Association, and the International Society for Child Indicators) at University Center in Greenville, SC, in April 2013. Correspondence concerning this article should be addressed to Susan Nall Bales, FrameWorks Institute, 1776 I Street, NW, 9th Floor, Washington, DC 20006. E-mail: [email protected] American Journal of Orthopsychiatry 2014, Vol. 84, No. 1, 12–18
© 2014 American Orthopsychiatric Association DOI: 10.1037/h0098944
the community
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What Is the Core of the Expert Story? FrameWorks strongly concurs with the Heaths’ conclusion that the starting point of knowledge translation lies in indentifying the knowledge to be translated. Indeed, one measure of stickiness must be the ability of a message to communicate not just anything, but the thing the communicator set out to impart. Finding this core among a diverse set of scientific disciplines and science practitioners can pose a daunting challenge. FrameWorks addressed this task by exploring the scientific discourse, in this case on child mental health, and supplementing this review with a series of interviews with experts. Subsequently, the story that emerged as the one scientists wish to tell was further refined as FrameWorks’ researchers attended, as participant-observers, several multidisciplinary meetings of child mental health experts, including a 2-day summit held in conjunction with the Society for Research on Child Development in 2009 and again in 2011. The expert story that emerged is, admittedly, a distillation of science principles and a consensus among scientists of what concepts and conclusions the field can agree are ready for public engagement and necessary if the public is to be able to use a scientific approach to issues confronting public policy and citizen decision-making. That is, we asked scientists to tell us what ordinary citizens need to understand if they are to distinguish between good and inferior investments in public programs designed to prevent and treat child mental illness and promote child mental health. Our efforts over time have yielded a “science story” that emphasizes these principles: • Child mental health and illness are real and occur even in very young children. • Child mental illness affects the child’s and family’s abilities to function.
• The brain is the key actor or location in which mental health or illness occurs. • Environmental factors within and outside of the home play a large role in influencing whether children will be mentally healthy or suffer mental problems. • Exposure to chronic and severe stressors in those environments generally has negative effects on child brain development and subsequent adult health. • Early interventions to deal with the symptoms of child mental illness and to improve child and family functioning provide the best hope for avoiding long-term dysfunctionality with costly consequences to society. At first glance, the expert story of child mental health appears disarmingly simple. Indeed, it is hard to imagine why this body of information would not pass “naturally” into public discourse. However, as is often evident in FrameWorks’ research on children’s issues, the public has developed ways of thinking about related issues that pose substantial hurdles to any consideration of this science story.
Is It Happening Naturally? To answer this question, FrameWorks adopted a cultural models perspective to discern the meaning-making process by which members of a culture make sense of relatively new or unfamiliar information. We initially conducted 20 interviews with Americans in Dallas, TX, and Cleveland, OH. Semistructured interviews of 1.5–2 hr took place in informal settings. Conducted by two researchers trained in cognitive theory, the interviews were transcribed and analyzed. The interviews were designed to elicit ways of thinking and talking about child and adult mental health, mental illness, causation, promotion, prevention, and treatment. Cultural models theory holds that people use a system of assumptions 13
and propositions about how the world works to organize the information and experiences that they encounter. Members of a cultural group make use of these shared understandings to reason and communicate with each other. If child mental health is to prove sticky in the sense that it can be discussed easily among ordinary Americans with some fidelity to the science story put forward earlier, then these interviews should yield multiple examples of consonance between public and expert thinking. They did not. Instead, the public struggled to even consider the first principle—that mental health or illness was possible in very young children. We draw below from the observations of our informants to illustrate the discrepancies between the expert and lay stories. Many informants asserted that children cannot have mental health because their minds work differently from adults. For example, one informant observed that he does not think children know they have mental health because they are not aware of what it is. He added that he thinks it is harder to understand mental health in children because children are not really aware of what they are getting or not getting because of their limited understanding. Children were perceived to have a limited ability to understand and remember emotions, and this inability made the idea of poor or good mental health “hard to think” for our informants. Once this way of thinking took hold, people were challenged to think what might promote or impede mental health in very young children. They simply were at a loss to think about programs, policies, or interventions that might make a difference. Indeed, they sometimes argued that, because the child does not “remember” the experience that might lead to poor mental health, the early years matter less for overall mental health than those when more adult reasoning and reflection are evident.
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the community Informants also asserted that children could have mental health, but that it is just a simpler version of adult mental health. “I just don’t know that kids are as anxious,” explained one informant. “I just think adults have a whole lot more to worry about.”1 People whose reasoning was grounded in the belief that children are really “little adults” found it difficult to understand why mental health programs would have to be tailored specifically to young children. Similar to adults, children need to deal with their emotions, they argued, and take responsibility. These two counterproductive ways of thinking about child mental health underscore the distortions that prevent the science story from taking hold without further translation. In FrameWorks’ assessment of the gaps between the expert story and the public’s assertions about how child mental health “works,” we observed two major points. First, whereas experts appreciate that genes interact with environments and are permeable, the public struggled to appreciate an ecocultural perspective, holding the family and the individual child responsible for outcomes. Genes were implicated only in mental illness and were then understood deterministically, without reference to environmental triggers. Second, the public’s narrow models of causation also drove them away from appreciating the experts’ wide range of effective treatments. For example, child mental illness was understood to be treatable, if at all, through chemicals. In sum, scientists and child mental health policy advocates can be fairly certain that, left to their own cognitive devices, Americans are unlikely to come to appreciate child mental health and the programs and policies that might promote it. Knowledge translation— or reframing—is in order if we are to achieve stickiness.
What Characterizes People’s Guessing Machines? One of the advantages of the Heaths’ recipe for stickiness is its metaphorical directive that we consider people’s default understandings— the opinions they bring to FrameWorks’ interviews—as machine-like. The machine metaphor helps us to appreciate the automaticity, predictability, and commonality with which cultural models are applied to “think” any given topic. As political scientists Polsby and Wildavsky famously observed, “Most (people) are not interested in most public issues most of the time.”2 Cultural models can be understood as the taken-for-granted, simplified representations of the world that allow people in social groups to converse about most things most of the time. They organize and simplify complex incoming information to connect it to familiar habits of thinking. At FrameWorks, we use the metaphor of a swamp to describe what’s in people’s mental ecology. Think of the features of a swamp as including gators who are ready to eat an incoming message and, at the same, as a place where many woody plants flourish. The task of a good communicator is to know what is in the swamp and to push back the gators and pull forward those positive ecologies that promise to grow new ways of thinking. The swamp diagram charts out these persistent, organized, shared ways of thinking that comprise the “guessing machine” people bring to child mental health. Drop any communication into this cognitive ecosystem and you can see how new information is reconfigured and reinterpreted by the dominance of the cultural models available to people in the swamp. Social scientists tell us that we are “fast and fru-
1
N. KENDALL-TAYLOR, CONFLICTING MODELS MIND IN MIND: MAPPING THE GAPS BETWEEN THE EXPERT AND THE PUBLIC UNDERSTANDINGS OF CHILD MENTAL HEALTH AS PART OF STRATEGIC FRAME ANALYSIS™ 18 (2009). OF
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N. W. POLSBY & A. WILDAVSKY, PRESIDENELECTIONS: CONTEMPORARY STRATEGIES OF AMERICAN ELECTORAL POLITICS 1(1988). TIAL
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gal”3 thinkers. By mapping the swamp of available ways people have of thinking any particular issue, communicators can achieve a better appreciation of the communications maneuvers they will have to make to keep their message sticky. In the swamp of children’s mental health in Figure 1, we see the systematic way that opinions are organized to allow people to “toggle” from one familiar model to another. We see how narrowly people model mental health and how they struggle to see environments as having any role in people’s achievement of it. Even when environments are mentioned, they are narrowly construed as parents and home. How can we get more ecological thinking into people’s guessing machines? Can’t we just assert it, or provide a few facts to support it, or show an image that makes the connection for people? With these questions, we move from the realm of descriptive research into the prescriptive or the world of reframing. By reframing, we mean changing the context and content of a communication—its use of values, metaphors, narrative, and so forth—in such a way that the communication has different effects on thinking. When we reframe, we provide cues that redirect thinking from the gators in the swamp toward the richer ecologies of thought.
What Would Break Their Guessing Machines? Communicators are too often advised to simply connect to the audience’s ways of thinking about an issue, to “resonate” with their innate beliefs. The beauty of the Heaths’ prescription for communications is that it recognizes that the only way to get people “unstuck” is to break their default patterns of thinking. 3 G. GIGERENZER & P. M. TODD, Fast and Frugal Heuristics: The Adaptive Toolbox, in Simple Heuristics That Make Us Smart 3 (G. GIGERENZER, P. M. TODD, & ABC RESEARCH GROUP ED., 1999).
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the community
Figure 1. FrameWorks uses the heuristic of a swamp to denote the cultural models that form an ecology of mind. Here we see the swamp of thinking that is top of mind on child mental health.
FrameWorks uses three powerful frame devices to break people’s guessing machines: values, metaphors, and narrative. I will discuss two of these— values and metaphors. The narrative component of child mental health is best understood in the context of the core story of early child development that FrameWorks has pioneered with the Harvard Center on the Developing Child and the Norlien Foundation in Alberta, Canada. We define values as enduring beliefs that orient individuals’ attitudes and behavior. They provide a motivational construct, defining the desirable goals people strive to attain. In this way, they serve as perceptual lenses on social issues. FrameWorks uses values as a way to reorient attributions of responsibility away from a unique focus on individuals toward a more balanced view in which individuals are also understood to be shaped by societal forces. In our work in the United States, it is frequently the case that social problems are seen by the public as primarily resulting from errors in individual choice and willpower. This assessment is often reinforced by media that implicitly or
explicitly frame social problems as the result of willful or uninformed deviations from the news you can use to better your lifestyle. Strategic Frame Analysis demonstrates across issues that the manipulation of values in communications results in changes in the way the public thinks about societal responsibility and impact, thereby shifting its evaluation of the merit and fit of public programs to public needs. When researchers at FrameWorks saw the kinds of easy defaults to individual responsibility that emerged from our research on child mental health, we began to experiment with putting different values at the top of the communication. Like a road sign, these values redirect thinking— although not always in the way we intend; it is not any value that produces stickiness, but only values that effectively resolve the problem observed in the knowledge transmission process. FrameWorks identified effective values by comparing the policy preferences and attitudes of respondents who were randomly assigned to exposure to a specific execution of a value, as opposed to those assigned to the control 15
group, which saw no treatment but answered the same policy questions. In large-scale online experiments, we were able to determine whether any values were capable of redirecting people’s guessing machines toward policies and attitudes that were more in line with expert thinking. Another key reframing tool is the explanatory metaphor. Numerous cognitive scientists have suggested how the contemplation of abstract, complex phenomena is routinely accomplished via metaphor and how powerfully metaphor can be used to suggest new ways of thinking. Explanatory metaphors are frame elements that fundamentally restructure the ways that people talk and reason about issues. As such, these metaphorical communications tools are useful in efforts to shift the interpretational frameworks that people access and use in processing information. By fortifying understandings of abstract phenomena, explanatory metaphors can potentially strengthen Americans’ support for policies that would improve discrete social problems. FrameWorks researcher Michael Erard explains that “a good metaphor is a device that leads people to think and talk about something they were not previously proficient in thinking or talking about. The metaphor device works this way because it preferentially cues some directions of thinking and talking over others; it transports a cluster of usable meanings into a domain with which listeners or readers are less familiar.”4 FrameWorks operates a metaphor kitchen, in which anthropologists, linguists, and sociologists collaborate to generate metaphors that appear to address the specific challenges identified in the cultural models research. Using various methods drawn from these disciplines (e.g., on-the-street interviews, quantitative tests, persistence trials, and usability tests), FrameWorks develops
4
MICHAEL ERARD, A METAPHOR IS A DEVICE THINKING AND TALKING: FRAMEWORKS’ APPLIED THEORY OF METAPHOR 4 (2011). FOR
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the community original metaphors to overcome the dominant default patterns observed and to provide new ways of thinking about a topic. It is only by conceptualizing the tasks that each of these reframing tools must play, by generating multiple candidates for these tasks, by testing them in controlled experiments, and by evaluating their effects on thinking and policy choice that FrameWorks is able to identify tools that work. In the end, stickiness is indeed an empirical pursuit.
How Can We Help People Refine Their Guessing Machines About Child Mental Health? FrameWorks research to date has yielded several frame elements that demonstrate significant power in breaking people’s guessing machines, refining their thinking in ways consonant with expert assessments, and making people more fluent and confident in their ability to explain child mental health to others. In an examination of the frame effects of five values tested against child mental health policies in an experimental survey of 4,200 registered voters in the fall of 2008, FrameWorks researchers found that broad values (e.g., American prosperity and ingenuity) had a greater effect on public support for child mental health policies than those that were more narrowly focused (e.g., the plight of vulnerable children or building a healthy society). The value of prosperity was explained as an investment in early childhood development, which served as an engine for the sustainable growth of the nation. Ingenuity focused on generating innovation to solve problems in early childhood development. This frame built on the notion that ingenuity is a dominant characteristic in our society and that its results are broadly shared across society. It is interesting to note that none of the frame elements that explicitly included health information as part of the frame showed statistically significant
changes in policy support compared with the control condition. That is, adding health information to the frame about health had no discernible effect on public support for child mental health policies. Our results showed that explicitly linking health and mental health was not an effective framing strategy for elevating policy support for child mental health. Put another way, simply asserting a role for mental health in child health did not break or refine people’s guessing machines. In addition to the explanatory metaphors identified in FrameWorks’ research on early child development— most notably, brain architecture, which was retested for its utility in the specific context of child mental health—a new metaphor was developed that showed strong and consistent contributions to thinking. This was the metaphor of levelness, or the idea that children and their environments need to be brought into a functional state. As confirmed in FrameWorks research, this metaphor shifted people away from their default thinking that children do not have mental health or that it is about individual control over emotional states. The metaphor also placed in the forefront ideas that underscore the reality of mental health and its implications for functionality. Further, people were led to appreciate a sense of preventive and remedial agency, countering their sense that “genes are set in stone.” It is difficult to appreciate a metaphor without an exemplary execution. We offer one of the tested ways of “doing levelness” that proved potent in our tests: Scientists say that children’s mental health affects how they socialize, how they learn, and how well they meet their potential. One way to think about child mental health is that it is like the levelness of a piece of furniture (e.g., a table). The levelness of a table is what makes it usable and able to function, just like the mental health of a child is what enables him or her to function and 16
Questions for Self-Assessment 1. Explain the concept of stickiness and discuss ways to achieve authentic stickiness with regard to a message. 2. Discuss the principles that Bales identifies as a part of the ”science story” of child mental health. What are some barriers to the public’s consideration of these principles? 3. Discuss FrameWorks’ use of values as a frame device to break people’s guessing machines. 4. How does the metaphor of levelness contribute to people’s thinking in the context of child mental health?
do many things. Some children’s brains develop on floors that are level. This is like saying that the children have healthy, supportive relationships and access to things such as good nutrition and health care. For other children, their brains develop on more sloped or slanted floors. This means they are exposed to abuse or violence, they have unreliable or unsupportive relationships, and they do not have access to key programs and resources. Remember that tables cannot make themselves level—they need attention from experts who understand levelness and stability and who can work on the table, the floor, or even both. We know that it is important to work on the floors and the tables early because little wobbles early on tend to become big wobbles later. Therefore, in general, a child’s mental health is like the stability and levelness of a table.5 Several ideas are critical to the concept of levelness: • Levelness is a quality, with analogy to a piece of furniture such as a table. 5 L. DAVEY, HOW TO TALK ABOUT CHILDREN’S MENTAL HEALTH: A FRAMEWORKS MESSAGE MEMO 12 (2010).
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the community • Levelness is important because it determines the functioning and usability of the table and, likewise, children’s mental health. • In reality, there are many degrees of the levelness of a table, as there are also degrees of levelness of the floors they are placed on. • There are many reasons that a table might be level or unlevel; it could depend on the condition of the table, the floor, or both. • Positive mental health can be achieved by adjusting the floor, the table, or both. Tables do not level themselves. They must be made that way or they require intervention by people who know about furniture and levelness. When FrameWorks researchers described the metaphor of levelness, participants could explain what child mental health is. The metaphor presents mental health as a brain-related phenomenon, but in a way that does not require reliance on genetics as the only explanation for the way the brain functions. Further, levelness organized our informants’ thinking around the functional aspects of child mental health. In other words, because they could grasp that a table that is not level cannot function, they were able to consider that child mental health is important to children’s overall functioning. Finally, equipped with the metaphor, informants recognized the existence of multiple causal factors of mental health and the need for flexible and multimodal intervention strategies that would address levelness. In discussion after discussion, informants were able to use, reformulate, and pass the levelness metaphor without its corruption. It is important to note that FrameWorks tested the levelness explanatory metaphor for its underlying metaphorical concept and in terms of the specific linguistic execution of that concept (levelness or leveling explicitly). In this way, we can be sure that the model represents an effective metaphorical concept and an effective expression of the concept. For these rea-
sons, although a certain latitude and flexibility in use and application are to be expected, even encouraged, the specific concept and language that appear in the report have empirically demonstrated effectiveness. As a general rule, members of the public overwhelmingly thought of mental health as emotional health—feeling happy or sad. Good mental health was seen as the result of experiencing positive emotions and dealing with the occurrence of negative emotions so that negative emotional states did not persist over time. By contrast, when thinking about levelness, participants readily talked about a wide range of factors that influence and shape mental health. They also viewed these determinants as factors that could be addressed and corrected to promote good mental health. Here is an example from one informant who was asked to consider and apply the metaphor: “This is a four-legged table . . . and then those [legs] would be the pillars of that child’s mind, that would be from their parents, teachers, health care and education, okay? So now the legs of this table have to be balanced, so that the level floor mirrors the top of the table. So we want the child to be level. We want them to be healthy, how do we make them healthy? How do we keep them on a level? Do we start with a level floor? Do we start with any floor and adjust the pillars? Do we start with a level table, and build the pillars up to it? Who do you look to? Where do you find what you need to get that child to a place where he’s ready to face the world on a nice level even keel? And so, you’re looking at the metaphor saying, a child’s health is like a level table, but that brings into account all that affects that child: whether their parents are together or separate, whether the grandparents raised the child or not, what kind of scientific research has been done on this, how can it be incorporated into the care of that child, and at what time should different parts of the science be brought in so that you end up 17
Suggestions for Further Reading Davey, L. (2010). How to talk about children’s mental health: A FrameWorks message memo. Washington, DC: FrameWorks Institute. Erard, M. (2011). A metaphor is a device for thinking and talking: FrameWorks’ applied theory of metaphor. Washington, DC: FrameWorks Institute. Erard, M., Kendall-Taylor, N., Simon, A., & Davey, L. (2010). The power of levelness: Making child mental health visible and concrete through a simplifying model. Washington, DC: FrameWorks Institute. Gigerenzer, G., Todd, P. M., and the ABC Research Group. (1999). Simple heuristics that make us smart. Oxford, United Kingdom: Oxford University Press. Heath, C., & Heath, D. (2007). Made to stick: Why some ideas survive and others die. New York, NY: Random House. Kendall-Taylor, N. (2009). Conflicting models of mind in mind: Mapping the gaps between the expert and the public understandings of child mental health as part of Strategic Frame Analysis.™ Washington, DC: FrameWorks Institute. Polsby, N. W., & Wildavsky, A. (1988). Presidential elections: Contemporary strategies of American electoral politics. New York, NY: Free Press. Shonkoff, J., & Bales, S. N. (2011). Science does not speak for itself: Translating child development research for the public and its policymakers. Child Development, 82, 17–32.
with a child who faces the world ready to go, you know, with a nice level look instead of being skewed one way or the other.6” In sum, potent reframing elements— values and metaphors— offered people a way to refine their guessing machines in favor of ways of thinking more consonant with that of experts. Of note, many of the seemingly logical responses to observed public thinking did little to move the needle. Indeed, trying to align child mental 6
M. ERARD, N. KENDALL-TAYLOR, A. SIMON, & L. DAVEY, THE POWER OF LEVELNESS: MAKING CHILD MENTAL HEALTH VISIBLE AND CONCRETE THROUGH A SIMPLIFYING MODEL 17 (2010).
the community health with health did not prove as efficacious for policy understanding as substituting a strong value.
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Conclusion The Heaths provided an ingenious way for communicators to rethink what it means to communicate effectively and what they need to know and do to accomplish stickiness. The FrameWorks Institute has demonstrated that this formula is not as easy
as it looks. Without a coherent and systematic pursuit of stickiness, communicators can easily fall prey to logical approaches to communicating that do not, in fact, have the desired effects. Knowledge translation is complicated. Unless communicators have access to sophisticated, multimethod research, it is unlikely that they can make progress in breaking and refining peoples’ guessing machines. FrameWorks offers several applied tools to help those who wish to commu-
nicate about child mental health overcome these challenges. However, apart from these more pragmatic tools, FrameWorks hopes to underscore for scientists and policy advocates the idea that stickiness is indeed an empirical pursuit; that is, without a theory of communications and a systematic pursuit we cannot become better communicators about child mental health. Recognizing this is an important prerequisite to moving the field to achieve stickiness.
Keywords: child mental health; stickiness; reframing; explanatory metaphor; Strategic Frame Analysis
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Haruv Award Lecture
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Stickiness Is an Empirical Pursuit: The Case for Reframing Child Mental Health Susan Nall Bales FrameWorks Institute
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veryone wants his or her issue to be sticky these days—to be talked about, get into the news, get in front of influential people, and so forth. However, the concept of stickiness, as put forward by scholars Chip and Dan Heath, is more than a fancy new term for salience. Rather, stickiness is defined in a way that recognizes the last several decades of research in the cognitive and social sciences on how people think about complex social issues. It poses appropriate goals for communicating issues that include the ability of a communication to convey the idea that the communicator intended, its innate resistance to default thinking, its redirective power, and its ability to bounce back even when the conversation degrades. In sum, authentic stickiness means more than getting an issue in the news; it means understanding and controlling the cognitive effects of such stories. The Heaths provide an elegant recipe for achieving stickiness. The starting place is the identification of the central message or finding the core. Communicators must then figure out what is counterintuitive about the message. In other
words, why isn’t the message being communicated naturally? The message must be communicated in a way that breaks the guessing machines (ways of thinking and understanding) of members of the audience. Finally, once the guessing machines have failed, audience members must be helped to refine their “machines.” In this article, we argue that stickiness is an empirical pursuit, one that requires an accretion of methods from across the cognitive and social sciences but which, if pursued systematically, can contribute significantly to public understanding. Drawing from the FrameWorks Institute’s development of Strategic Frame Analysis, we demonstrate how our methods can be used to pursue stickiness and with what effects. Applying this approach to the issue of child mental health, we demonstrate why approaches that posit resonance or salience are likely to prove ineffective in helping the public to prioritize prevention and treatment for child mental illness or promotion of child mental health. According to our research, how the public understands or “models” child mental health poses a considerable roadblock to engagement and policy support.
We make these claims based on more than 5 years of qualitative and quantitative research conducted in the United States and Canada on how people think about child mental health. Beginning in 2008, as part of a partnership with the Center on the Developing Child at Harvard University and with support from the Endowment for Health (NH), researchers at the FrameWorks Institute designed and conducted a series of studies that roughly parallel the process suggested by the Heaths. Following the reports and recommendations that emanated from this foundational inquiry, additional research has been conducted in Alberta, Canada, and in Jacksonville, FL, to further verify the initial findings and retest recommendations in these divergent locales. The FrameWorks Institute’s research base on child mental health alone comprises more than 12,000 informants and includes reviews of 4,000 news and scholarly articles. It is from this multimethod database that we draw to explore the challenge of making child mental health a stickier topic in public thinking.
This article is based on the inaugural Haruv Lecture presented at the Fifth Greenville Family Symposium (sponsored by the American Orthopsychiatric Association, the Clemson University Institute on Family and Neighborhood Life, the Haruv Institute, the International Family Therapy Association, and the International Society for Child Indicators) at University Center in Greenville, SC, in April 2013. Correspondence concerning this article should be addressed to Susan Nall Bales, FrameWorks Institute, 1776 I Street, NW, 9th Floor, Washington, DC 20006. E-mail: [email protected] American Journal of Orthopsychiatry 2014, Vol. 84, No. 1, 12–18
© 2014 American Orthopsychiatric Association DOI: 10.1037/h0098944
the community
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What Is the Core of the Expert Story? FrameWorks strongly concurs with the Heaths’ conclusion that the starting point of knowledge translation lies in indentifying the knowledge to be translated. Indeed, one measure of stickiness must be the ability of a message to communicate not just anything, but the thing the communicator set out to impart. Finding this core among a diverse set of scientific disciplines and science practitioners can pose a daunting challenge. FrameWorks addressed this task by exploring the scientific discourse, in this case on child mental health, and supplementing this review with a series of interviews with experts. Subsequently, the story that emerged as the one scientists wish to tell was further refined as FrameWorks’ researchers attended, as participant-observers, several multidisciplinary meetings of child mental health experts, including a 2-day summit held in conjunction with the Society for Research on Child Development in 2009 and again in 2011. The expert story that emerged is, admittedly, a distillation of science principles and a consensus among scientists of what concepts and conclusions the field can agree are ready for public engagement and necessary if the public is to be able to use a scientific approach to issues confronting public policy and citizen decision-making. That is, we asked scientists to tell us what ordinary citizens need to understand if they are to distinguish between good and inferior investments in public programs designed to prevent and treat child mental illness and promote child mental health. Our efforts over time have yielded a “science story” that emphasizes these principles: • Child mental health and illness are real and occur even in very young children. • Child mental illness affects the child’s and family’s abilities to function.
• The brain is the key actor or location in which mental health or illness occurs. • Environmental factors within and outside of the home play a large role in influencing whether children will be mentally healthy or suffer mental problems. • Exposure to chronic and severe stressors in those environments generally has negative effects on child brain development and subsequent adult health. • Early interventions to deal with the symptoms of child mental illness and to improve child and family functioning provide the best hope for avoiding long-term dysfunctionality with costly consequences to society. At first glance, the expert story of child mental health appears disarmingly simple. Indeed, it is hard to imagine why this body of information would not pass “naturally” into public discourse. However, as is often evident in FrameWorks’ research on children’s issues, the public has developed ways of thinking about related issues that pose substantial hurdles to any consideration of this science story.
Is It Happening Naturally? To answer this question, FrameWorks adopted a cultural models perspective to discern the meaning-making process by which members of a culture make sense of relatively new or unfamiliar information. We initially conducted 20 interviews with Americans in Dallas, TX, and Cleveland, OH. Semistructured interviews of 1.5–2 hr took place in informal settings. Conducted by two researchers trained in cognitive theory, the interviews were transcribed and analyzed. The interviews were designed to elicit ways of thinking and talking about child and adult mental health, mental illness, causation, promotion, prevention, and treatment. Cultural models theory holds that people use a system of assumptions 13
and propositions about how the world works to organize the information and experiences that they encounter. Members of a cultural group make use of these shared understandings to reason and communicate with each other. If child mental health is to prove sticky in the sense that it can be discussed easily among ordinary Americans with some fidelity to the science story put forward earlier, then these interviews should yield multiple examples of consonance between public and expert thinking. They did not. Instead, the public struggled to even consider the first principle—that mental health or illness was possible in very young children. We draw below from the observations of our informants to illustrate the discrepancies between the expert and lay stories. Many informants asserted that children cannot have mental health because their minds work differently from adults. For example, one informant observed that he does not think children know they have mental health because they are not aware of what it is. He added that he thinks it is harder to understand mental health in children because children are not really aware of what they are getting or not getting because of their limited understanding. Children were perceived to have a limited ability to understand and remember emotions, and this inability made the idea of poor or good mental health “hard to think” for our informants. Once this way of thinking took hold, people were challenged to think what might promote or impede mental health in very young children. They simply were at a loss to think about programs, policies, or interventions that might make a difference. Indeed, they sometimes argued that, because the child does not “remember” the experience that might lead to poor mental health, the early years matter less for overall mental health than those when more adult reasoning and reflection are evident.
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the community Informants also asserted that children could have mental health, but that it is just a simpler version of adult mental health. “I just don’t know that kids are as anxious,” explained one informant. “I just think adults have a whole lot more to worry about.”1 People whose reasoning was grounded in the belief that children are really “little adults” found it difficult to understand why mental health programs would have to be tailored specifically to young children. Similar to adults, children need to deal with their emotions, they argued, and take responsibility. These two counterproductive ways of thinking about child mental health underscore the distortions that prevent the science story from taking hold without further translation. In FrameWorks’ assessment of the gaps between the expert story and the public’s assertions about how child mental health “works,” we observed two major points. First, whereas experts appreciate that genes interact with environments and are permeable, the public struggled to appreciate an ecocultural perspective, holding the family and the individual child responsible for outcomes. Genes were implicated only in mental illness and were then understood deterministically, without reference to environmental triggers. Second, the public’s narrow models of causation also drove them away from appreciating the experts’ wide range of effective treatments. For example, child mental illness was understood to be treatable, if at all, through chemicals. In sum, scientists and child mental health policy advocates can be fairly certain that, left to their own cognitive devices, Americans are unlikely to come to appreciate child mental health and the programs and policies that might promote it. Knowledge translation— or reframing—is in order if we are to achieve stickiness.
What Characterizes People’s Guessing Machines? One of the advantages of the Heaths’ recipe for stickiness is its metaphorical directive that we consider people’s default understandings— the opinions they bring to FrameWorks’ interviews—as machine-like. The machine metaphor helps us to appreciate the automaticity, predictability, and commonality with which cultural models are applied to “think” any given topic. As political scientists Polsby and Wildavsky famously observed, “Most (people) are not interested in most public issues most of the time.”2 Cultural models can be understood as the taken-for-granted, simplified representations of the world that allow people in social groups to converse about most things most of the time. They organize and simplify complex incoming information to connect it to familiar habits of thinking. At FrameWorks, we use the metaphor of a swamp to describe what’s in people’s mental ecology. Think of the features of a swamp as including gators who are ready to eat an incoming message and, at the same, as a place where many woody plants flourish. The task of a good communicator is to know what is in the swamp and to push back the gators and pull forward those positive ecologies that promise to grow new ways of thinking. The swamp diagram charts out these persistent, organized, shared ways of thinking that comprise the “guessing machine” people bring to child mental health. Drop any communication into this cognitive ecosystem and you can see how new information is reconfigured and reinterpreted by the dominance of the cultural models available to people in the swamp. Social scientists tell us that we are “fast and fru-
1
N. KENDALL-TAYLOR, CONFLICTING MODELS MIND IN MIND: MAPPING THE GAPS BETWEEN THE EXPERT AND THE PUBLIC UNDERSTANDINGS OF CHILD MENTAL HEALTH AS PART OF STRATEGIC FRAME ANALYSIS™ 18 (2009). OF
2
N. W. POLSBY & A. WILDAVSKY, PRESIDENELECTIONS: CONTEMPORARY STRATEGIES OF AMERICAN ELECTORAL POLITICS 1(1988). TIAL
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gal”3 thinkers. By mapping the swamp of available ways people have of thinking any particular issue, communicators can achieve a better appreciation of the communications maneuvers they will have to make to keep their message sticky. In the swamp of children’s mental health in Figure 1, we see the systematic way that opinions are organized to allow people to “toggle” from one familiar model to another. We see how narrowly people model mental health and how they struggle to see environments as having any role in people’s achievement of it. Even when environments are mentioned, they are narrowly construed as parents and home. How can we get more ecological thinking into people’s guessing machines? Can’t we just assert it, or provide a few facts to support it, or show an image that makes the connection for people? With these questions, we move from the realm of descriptive research into the prescriptive or the world of reframing. By reframing, we mean changing the context and content of a communication—its use of values, metaphors, narrative, and so forth—in such a way that the communication has different effects on thinking. When we reframe, we provide cues that redirect thinking from the gators in the swamp toward the richer ecologies of thought.
What Would Break Their Guessing Machines? Communicators are too often advised to simply connect to the audience’s ways of thinking about an issue, to “resonate” with their innate beliefs. The beauty of the Heaths’ prescription for communications is that it recognizes that the only way to get people “unstuck” is to break their default patterns of thinking. 3 G. GIGERENZER & P. M. TODD, Fast and Frugal Heuristics: The Adaptive Toolbox, in Simple Heuristics That Make Us Smart 3 (G. GIGERENZER, P. M. TODD, & ABC RESEARCH GROUP ED., 1999).
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the community
Figure 1. FrameWorks uses the heuristic of a swamp to denote the cultural models that form an ecology of mind. Here we see the swamp of thinking that is top of mind on child mental health.
FrameWorks uses three powerful frame devices to break people’s guessing machines: values, metaphors, and narrative. I will discuss two of these— values and metaphors. The narrative component of child mental health is best understood in the context of the core story of early child development that FrameWorks has pioneered with the Harvard Center on the Developing Child and the Norlien Foundation in Alberta, Canada. We define values as enduring beliefs that orient individuals’ attitudes and behavior. They provide a motivational construct, defining the desirable goals people strive to attain. In this way, they serve as perceptual lenses on social issues. FrameWorks uses values as a way to reorient attributions of responsibility away from a unique focus on individuals toward a more balanced view in which individuals are also understood to be shaped by societal forces. In our work in the United States, it is frequently the case that social problems are seen by the public as primarily resulting from errors in individual choice and willpower. This assessment is often reinforced by media that implicitly or
explicitly frame social problems as the result of willful or uninformed deviations from the news you can use to better your lifestyle. Strategic Frame Analysis demonstrates across issues that the manipulation of values in communications results in changes in the way the public thinks about societal responsibility and impact, thereby shifting its evaluation of the merit and fit of public programs to public needs. When researchers at FrameWorks saw the kinds of easy defaults to individual responsibility that emerged from our research on child mental health, we began to experiment with putting different values at the top of the communication. Like a road sign, these values redirect thinking— although not always in the way we intend; it is not any value that produces stickiness, but only values that effectively resolve the problem observed in the knowledge transmission process. FrameWorks identified effective values by comparing the policy preferences and attitudes of respondents who were randomly assigned to exposure to a specific execution of a value, as opposed to those assigned to the control 15
group, which saw no treatment but answered the same policy questions. In large-scale online experiments, we were able to determine whether any values were capable of redirecting people’s guessing machines toward policies and attitudes that were more in line with expert thinking. Another key reframing tool is the explanatory metaphor. Numerous cognitive scientists have suggested how the contemplation of abstract, complex phenomena is routinely accomplished via metaphor and how powerfully metaphor can be used to suggest new ways of thinking. Explanatory metaphors are frame elements that fundamentally restructure the ways that people talk and reason about issues. As such, these metaphorical communications tools are useful in efforts to shift the interpretational frameworks that people access and use in processing information. By fortifying understandings of abstract phenomena, explanatory metaphors can potentially strengthen Americans’ support for policies that would improve discrete social problems. FrameWorks researcher Michael Erard explains that “a good metaphor is a device that leads people to think and talk about something they were not previously proficient in thinking or talking about. The metaphor device works this way because it preferentially cues some directions of thinking and talking over others; it transports a cluster of usable meanings into a domain with which listeners or readers are less familiar.”4 FrameWorks operates a metaphor kitchen, in which anthropologists, linguists, and sociologists collaborate to generate metaphors that appear to address the specific challenges identified in the cultural models research. Using various methods drawn from these disciplines (e.g., on-the-street interviews, quantitative tests, persistence trials, and usability tests), FrameWorks develops
4
MICHAEL ERARD, A METAPHOR IS A DEVICE THINKING AND TALKING: FRAMEWORKS’ APPLIED THEORY OF METAPHOR 4 (2011). FOR
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the community original metaphors to overcome the dominant default patterns observed and to provide new ways of thinking about a topic. It is only by conceptualizing the tasks that each of these reframing tools must play, by generating multiple candidates for these tasks, by testing them in controlled experiments, and by evaluating their effects on thinking and policy choice that FrameWorks is able to identify tools that work. In the end, stickiness is indeed an empirical pursuit.
How Can We Help People Refine Their Guessing Machines About Child Mental Health? FrameWorks research to date has yielded several frame elements that demonstrate significant power in breaking people’s guessing machines, refining their thinking in ways consonant with expert assessments, and making people more fluent and confident in their ability to explain child mental health to others. In an examination of the frame effects of five values tested against child mental health policies in an experimental survey of 4,200 registered voters in the fall of 2008, FrameWorks researchers found that broad values (e.g., American prosperity and ingenuity) had a greater effect on public support for child mental health policies than those that were more narrowly focused (e.g., the plight of vulnerable children or building a healthy society). The value of prosperity was explained as an investment in early childhood development, which served as an engine for the sustainable growth of the nation. Ingenuity focused on generating innovation to solve problems in early childhood development. This frame built on the notion that ingenuity is a dominant characteristic in our society and that its results are broadly shared across society. It is interesting to note that none of the frame elements that explicitly included health information as part of the frame showed statistically significant
changes in policy support compared with the control condition. That is, adding health information to the frame about health had no discernible effect on public support for child mental health policies. Our results showed that explicitly linking health and mental health was not an effective framing strategy for elevating policy support for child mental health. Put another way, simply asserting a role for mental health in child health did not break or refine people’s guessing machines. In addition to the explanatory metaphors identified in FrameWorks’ research on early child development— most notably, brain architecture, which was retested for its utility in the specific context of child mental health—a new metaphor was developed that showed strong and consistent contributions to thinking. This was the metaphor of levelness, or the idea that children and their environments need to be brought into a functional state. As confirmed in FrameWorks research, this metaphor shifted people away from their default thinking that children do not have mental health or that it is about individual control over emotional states. The metaphor also placed in the forefront ideas that underscore the reality of mental health and its implications for functionality. Further, people were led to appreciate a sense of preventive and remedial agency, countering their sense that “genes are set in stone.” It is difficult to appreciate a metaphor without an exemplary execution. We offer one of the tested ways of “doing levelness” that proved potent in our tests: Scientists say that children’s mental health affects how they socialize, how they learn, and how well they meet their potential. One way to think about child mental health is that it is like the levelness of a piece of furniture (e.g., a table). The levelness of a table is what makes it usable and able to function, just like the mental health of a child is what enables him or her to function and 16
Questions for Self-Assessment 1. Explain the concept of stickiness and discuss ways to achieve authentic stickiness with regard to a message. 2. Discuss the principles that Bales identifies as a part of the ”science story” of child mental health. What are some barriers to the public’s consideration of these principles? 3. Discuss FrameWorks’ use of values as a frame device to break people’s guessing machines. 4. How does the metaphor of levelness contribute to people’s thinking in the context of child mental health?
do many things. Some children’s brains develop on floors that are level. This is like saying that the children have healthy, supportive relationships and access to things such as good nutrition and health care. For other children, their brains develop on more sloped or slanted floors. This means they are exposed to abuse or violence, they have unreliable or unsupportive relationships, and they do not have access to key programs and resources. Remember that tables cannot make themselves level—they need attention from experts who understand levelness and stability and who can work on the table, the floor, or even both. We know that it is important to work on the floors and the tables early because little wobbles early on tend to become big wobbles later. Therefore, in general, a child’s mental health is like the stability and levelness of a table.5 Several ideas are critical to the concept of levelness: • Levelness is a quality, with analogy to a piece of furniture such as a table. 5 L. DAVEY, HOW TO TALK ABOUT CHILDREN’S MENTAL HEALTH: A FRAMEWORKS MESSAGE MEMO 12 (2010).
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the community • Levelness is important because it determines the functioning and usability of the table and, likewise, children’s mental health. • In reality, there are many degrees of the levelness of a table, as there are also degrees of levelness of the floors they are placed on. • There are many reasons that a table might be level or unlevel; it could depend on the condition of the table, the floor, or both. • Positive mental health can be achieved by adjusting the floor, the table, or both. Tables do not level themselves. They must be made that way or they require intervention by people who know about furniture and levelness. When FrameWorks researchers described the metaphor of levelness, participants could explain what child mental health is. The metaphor presents mental health as a brain-related phenomenon, but in a way that does not require reliance on genetics as the only explanation for the way the brain functions. Further, levelness organized our informants’ thinking around the functional aspects of child mental health. In other words, because they could grasp that a table that is not level cannot function, they were able to consider that child mental health is important to children’s overall functioning. Finally, equipped with the metaphor, informants recognized the existence of multiple causal factors of mental health and the need for flexible and multimodal intervention strategies that would address levelness. In discussion after discussion, informants were able to use, reformulate, and pass the levelness metaphor without its corruption. It is important to note that FrameWorks tested the levelness explanatory metaphor for its underlying metaphorical concept and in terms of the specific linguistic execution of that concept (levelness or leveling explicitly). In this way, we can be sure that the model represents an effective metaphorical concept and an effective expression of the concept. For these rea-
sons, although a certain latitude and flexibility in use and application are to be expected, even encouraged, the specific concept and language that appear in the report have empirically demonstrated effectiveness. As a general rule, members of the public overwhelmingly thought of mental health as emotional health—feeling happy or sad. Good mental health was seen as the result of experiencing positive emotions and dealing with the occurrence of negative emotions so that negative emotional states did not persist over time. By contrast, when thinking about levelness, participants readily talked about a wide range of factors that influence and shape mental health. They also viewed these determinants as factors that could be addressed and corrected to promote good mental health. Here is an example from one informant who was asked to consider and apply the metaphor: “This is a four-legged table . . . and then those [legs] would be the pillars of that child’s mind, that would be from their parents, teachers, health care and education, okay? So now the legs of this table have to be balanced, so that the level floor mirrors the top of the table. So we want the child to be level. We want them to be healthy, how do we make them healthy? How do we keep them on a level? Do we start with a level floor? Do we start with any floor and adjust the pillars? Do we start with a level table, and build the pillars up to it? Who do you look to? Where do you find what you need to get that child to a place where he’s ready to face the world on a nice level even keel? And so, you’re looking at the metaphor saying, a child’s health is like a level table, but that brings into account all that affects that child: whether their parents are together or separate, whether the grandparents raised the child or not, what kind of scientific research has been done on this, how can it be incorporated into the care of that child, and at what time should different parts of the science be brought in so that you end up 17
Suggestions for Further Reading Davey, L. (2010). How to talk about children’s mental health: A FrameWorks message memo. Washington, DC: FrameWorks Institute. Erard, M. (2011). A metaphor is a device for thinking and talking: FrameWorks’ applied theory of metaphor. Washington, DC: FrameWorks Institute. Erard, M., Kendall-Taylor, N., Simon, A., & Davey, L. (2010). The power of levelness: Making child mental health visible and concrete through a simplifying model. Washington, DC: FrameWorks Institute. Gigerenzer, G., Todd, P. M., and the ABC Research Group. (1999). Simple heuristics that make us smart. Oxford, United Kingdom: Oxford University Press. Heath, C., & Heath, D. (2007). Made to stick: Why some ideas survive and others die. New York, NY: Random House. Kendall-Taylor, N. (2009). Conflicting models of mind in mind: Mapping the gaps between the expert and the public understandings of child mental health as part of Strategic Frame Analysis.™ Washington, DC: FrameWorks Institute. Polsby, N. W., & Wildavsky, A. (1988). Presidential elections: Contemporary strategies of American electoral politics. New York, NY: Free Press. Shonkoff, J., & Bales, S. N. (2011). Science does not speak for itself: Translating child development research for the public and its policymakers. Child Development, 82, 17–32.
with a child who faces the world ready to go, you know, with a nice level look instead of being skewed one way or the other.6” In sum, potent reframing elements— values and metaphors— offered people a way to refine their guessing machines in favor of ways of thinking more consonant with that of experts. Of note, many of the seemingly logical responses to observed public thinking did little to move the needle. Indeed, trying to align child mental 6
M. ERARD, N. KENDALL-TAYLOR, A. SIMON, & L. DAVEY, THE POWER OF LEVELNESS: MAKING CHILD MENTAL HEALTH VISIBLE AND CONCRETE THROUGH A SIMPLIFYING MODEL 17 (2010).
the community health with health did not prove as efficacious for policy understanding as substituting a strong value.
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Conclusion The Heaths provided an ingenious way for communicators to rethink what it means to communicate effectively and what they need to know and do to accomplish stickiness. The FrameWorks Institute has demonstrated that this formula is not as easy
as it looks. Without a coherent and systematic pursuit of stickiness, communicators can easily fall prey to logical approaches to communicating that do not, in fact, have the desired effects. Knowledge translation is complicated. Unless communicators have access to sophisticated, multimethod research, it is unlikely that they can make progress in breaking and refining peoples’ guessing machines. FrameWorks offers several applied tools to help those who wish to commu-
nicate about child mental health overcome these challenges. However, apart from these more pragmatic tools, FrameWorks hopes to underscore for scientists and policy advocates the idea that stickiness is indeed an empirical pursuit; that is, without a theory of communications and a systematic pursuit we cannot become better communicators about child mental health. Recognizing this is an important prerequisite to moving the field to achieve stickiness.
Keywords: child mental health; stickiness; reframing; explanatory metaphor; Strategic Frame Analysis
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