Input from Persons with Lived Experience
I think it is critical in Human Service delivery that time is spent speaking with recipients of services and benefits to hear directly from them. In the projects we have done – from homeless counts that use surveys to developing long term affordable housing strategies; program evaluations to redesigning income benefits; strategic planning to developing plans to end homelessness – we fundamentally believe that the voice of the consumer must be heard in legitimate, defensible ways to inform and empower end users of services. The adage “Nothing about us without us” from the psychiatric survivor movement rings very true in our work.
Here are 12 tips to introduce/improve interactions with persons with lived experience in your work.
1. Have a research design.
You can’t gather this sort of input and use it responsibly if you have not sorted out the methods by which you are going to gather information and the ethics involved in having people with lived experience involved. Just going out to talk with people is insufficient. How, when, where, why, who and what is spoken about are all essential questions that need to be answered before you start talking to people.
2. Seek informed consent.
Just because someone has received a service from you doesn’t mean they have to talk to you. Same goes for someone who may be eligible for a service but has never accessed a service. People have to be able to provide informed consent to provide their input and for you to use it. It is ethically dubious to assume that just because you are serving someone or can serve someone that they are implicitly consenting for you to use their input.
3. Don’t talk down to people.
Persons with lived experience have unique subject matter expertise. Yet a lot of the time the people engaged with them speak down to them. If the questions, tone or situation for the conversation is in anyway condescending, you’ve got it all wrong.
4. Bring in outsiders.
The people engaged with consumers of your services (past or present) to get their input should be different than the people that they rely on for service on a day to day basis. Bring in a consultant, fellow agency, volunteers or staff from a different program area to get input from the people with lived experience. Otherwise if people even think there is an iota of possibility that what they tell you having an impact on the quality or quantity of service they receive, sunshine will be blown up your derriere.
5. Set the tone.
You can’t just feel people out or end up trying to be a chameleon who can “talk street” or act like someone you are not. It is up to the person getting input from persons with lived experience to set the tone for the conversation…what the conversation is about, how long the conversation will last, how the information will be used, etc.
6. Do something with what you hear.
If you really want people with lived experience to have a meaningful impact in how you deliver services then you must act upon the feedback and other information you receive. Asking for input but doing nothing about it essentially de-values the time and input of people with lived experience.
7. Empower people to have a say.
Honest feedback and input is necessary. People should be encouraged to be as open as they feel comfortable knowing in advance that there are not repercussions for being forthright.
8. Don’t limit responses to folks that are accustomed to participating.
Some communities “suffer” from the same people with lived experience repeatedly on the same types of advisory groups to provide the same type of feedback. While that is all well and good you can’t limit input to just these people. You have to find ways of engaging with those individuals unaware or unaccustomed to providing the sort of input being sought.
9. Be willing to go to places not usually associated with research/feedback.
Related to number 8 above, I have found it very interesting and helpful to go out of my way to get input. I have gotten better response rates and more honest responses, for example, standing in an underpass near a homeless shelter than at the homeless shelter itself. I have done better getting outreach vans to drop me off at encampments and pick me up later than staying with me. I have strolled the streets and alleyways with people involved with sex work. I have stood in the foyer of public housing buildings. I have spent hours on a park bench in a neighborhood chatting to people who pass by. I have been out first thing in the morning as well as the middle of the night. If we want to honor the voice of people with lived experience it has to be about the places and times of day that make sense for them, not us.
10. Don’t confuse lived experience with expertise.
Just because someone has experienced, say, homelessness does not mean they are an expert on all matters of homelessness. There are some people who have never experienced homelessness that have a lot of expertise in homelessness. It is what the input is about that matters, not that all input is of expert caliber. Let me give you an example…I have had my appendix out and my gall bladder out, and I have broken my hip. I would consider myself to have some expertise in describing the pain, approach to getting care and how to be rehabilitated afterwards for any of these three conditions. However, I would not consider myself to have the expertise to prescribe pain medication, conduct the surgery, insert pins into a person’s bones or outline an appropriate meal plan or exercise schedule.
11. Gather the input on a scheduled basis.
Gather input when you say you will gather input from the people you generally intend to get input from. If the information collection from people with lived experience is seen as haphazard more than intentional you may not get the sort of rigorous feedback that you will benefit most from through the experience.
12. Don’t underestimate access to technology.
I now find it comical when service providers tell me not to use Twitter or Facebook or Survey Monkey or similar tools to get input from people who are homeless or experience precarious housing or poverty. Why? Because I tend to get response rates much higher than one might expect from the general population. Economically poor and homeless people tend to have considerable access to technology and wherewithal to use it. Avoiding these opportunities is grossly limiting a source for gathering input.
I hope some of these tips will help you in your work and improve your services.
Generating Data is Outstripping our Ability to Interpret It
I was reading a newspaper article the other day about it now being possible to create the genetic map of an unborn child. Fascinating stuff. But there was one line in the article that really got me thinking about data more than genetics itself: “The capacity of genomics to generate data is outstripping our ability to interpret it in useful ways.”
I don’t think this phenomenon is limited to genomics. I can think of lots of fields and industries and individual organizations that place a premium on collecting data but do not have the ability to interpret it in useful ways.
Some errors that drive me around the bend:
Data for data’s sake. I have encountered too many organizations where they jumped on the data bandwagon and collected oodles of info that they never use. They devote loads of time to data for data sake without doing anything with the data. Data should drive decisions and program improvements.
Feeling. I once had a boss that used gut check and nothing else to see if he could use the data to tell the story he wanted to tell. Ugh. If ever the data collided with his world view he would either want to bury the data, have us re-run the analysis (which came up with the same conclusions time and again) or would challenge the methods of data collection (there was nothing wrong with the collection methods). We cannot shy away from data when it tells us something different than what we were expecting or wanted to hear. Data won’t always tell you that you are doing an awesome job.
Incorrect language. This is a well-intentioned error, but a common one all the same. People who don’t use data a lot will use words like “significant” or “sample” in ways that mean something completely different to data nerds and analysts than what they were intending. The result? People question their findings because of the incorrect language use. We could also get into incorrect manipulation of data (like averaging averages) but I won’t go there.
Data analysis plan after the fact. Good scientific and defensible analysis of data requires us to have a good plan for how the data will be looked at before launching into the analysis of the data. Otherwise there can always be the accusation that the data analysis set up after the fact was done in such a way so as to bias the findings.
People without any training drawing conclusions. Data analysis isn’t something that just anyone can do without proper training. We need to be infusing instruction on how to interpret data and take action upon it at the frontline and supervisory levels if we want organizations to use it properly. Oh, and Boards and Funders and Government too where there seems to be no shortage of people who have no clue how to read and interpret data and yet make huge decisions based upon the data.
But it isn’t just about interpretation or the common errors noted above. One major problem is that in many instances the data driven mentality has resulted in groups collecting way more data than they need (or at least trying to collect). A few things that happen as a result:
Incomplete data sets. Hiring an outside expert to make sense of your data when the data sets are largely incomplete will not result in robust findings. Without some key fields filled in within your data system it is sometimes possible to make inferences and use proxy data, but it is not as reliable. We need staff to feel that data entry is part of the real work that they do – not something that happens after the real work is done.
Constantly tweaking data asks. I could throttle (as I’m sure some service providers could as well) senior managers or funders that keep changing what data they want. Doing a file crawl or file audit to try and track down various pieces of data is not only inefficient, it is problematic by way of accuracy in many instances. Data asks should only be altered at the start of a funding year and should only be changed from one year to the next when there is a compelling reason to do so.
Insufficient infrastructure to support analysis. And then there are times when service providers collect all of the data requested and send it to their funder. I have lost count of the number of times there are not enough staff with the Funder to pull the data together across the agencies, undertake the necessary quality assurance analysis on the data, analyze the data appropriately and report back out on the data. It goes into a black hole. Tragic.
So if you want to make the best use of the data collection and analysis in the environment you work in, ask yourself these questions:
Do we correctly capture the information we need to know if we are meeting our stated objectives? Yes, the data collected should be directly linked to the objectives of your activities. Do not collect more than you need to. Keep it simple. And here is a tip – pull together a small group of people who do the work on the frontlines to help define the data to be collected relative to the objectives. They are a great barometer on what is helpful and what is crap.
Do we have a plan for analyzing this information in regular intervals? Set out an analysis and reporting out schedule in advance. Don’t get too ambitious. Figure out what needs to be shared internally and what should be shared externally, how and when. Once you have the plan, stick to it. If you let it slide it is amazing how complacent the organization will be about data and reporting out.
What do we do as a result of this information? This isn’t data collection and analysis just because a funder told you had to in order to get the money. You need to get into a mindset that if you collect only the data you need you should be able to reflect on service delivery and make it better.
How can we do this better? Take a step back once every 6-12 months and ask yourselves how you can collect and use data better. You may find that this is the key to decreasing the amount of data that you collect and doing more meaningful things with the data you do have to improve programming and service outputs and outcomes.
For the umpteenth time, Iain will be presenting Data and Performance Simplified at the National Alliance to End Homelessness Conference in Washington, DC this July – and he is happy to do so. Stay tuned to see the presentation on the Alliance website shortly after the conference.
POST HOC ERGO PROPTER HOC
Welcome to today’s Latin lesson. “Post hoc ergo propter hoc” means “after it, therefore because of it”. It is the title of a West Wing episode from Season 1 (and you can watch the scene herewhere it is discussed). It also happens to be the sort of thing they teach you if you study logic and comes in handy if you love data and helping organizations improve services.
In a nutshell, you can write up the formula like this:
X happened, then Y happened
Therefore, X caused Y
You can also have people reverse elements of the equation. Let’s say it really sucks for Y to happen. In that case, if you avoid or prevent X then Y won’t occur.
If you look just at the order of events rather than the influences on the events you can draw oodles of false conclusions. A temporal succession of events is not evidence of a causal relation. Does a rooster raising a cacophony just before the sun rises cause the sun to rise?
A lot of times when engaged with people, there is a reliance on anecdotes to explain causation rather than examining influences independently. The problem with anecdotes (amongst many) is that they are open to subjective interpretation, have the bias of the anecdote teller, rely considerably on intuition and frequently ask the listener to believe based upon the existing relationship between anecdote-teller and anecdote-listener rather than facts.
For those of you who love to support or play sports, you know that there is a lot of superstitions that occur which fall victim to post hoc ergo propter hoc thinking. As a species we are in search for meaning. We use superstition to sometimes create explanations for things simply rather than looking at other factors that may have had an influence. Was it really putting on the yellow headband before the tennis match that made her win? Maybe it was that the headband kept the hair out of her eyes. Or maybe it was nothing to do with her headband…that her opponent was under the weather…or that she had trained hard on her serve and footwork…or the match started with the wind at her back…and so on. To state that putting on the yellow headband before the match that she won caused her to win the match just doesn’t cut it.
Key messaging from a public relations perspective frequently falls victim to post hoc ergo propter hoc thinking. In one community recently I heard the following statement from a local elected official, “Since 2002 when we opened the [name of facility withheld] homelessness has dropped 11.78%.”
It begs a lot of questions. What has happened in the local economy over the same period of time? The community was at double digits of unemployment when the facility opened but steadily declined even through the recession. What about the more steady and rapid decline in homelessness after the 10 Year Plan and new programming were introduced in 2007? What about the investments in professional development for staff in the community to the tune of almost $200,000 in the past three years to learn better strategies to help people access and maintain housing? What about the availability of more rent subsidies available since 2008? So, did the facility opening cause the drop in homelessness? It may be part of the equation depending on who the facility caters to and the programs operated out of the facility, but unless you look at the whole picture you can’t say that the drop in homelessness after the facility being opened caused the drop in homelessness. (And as an aside, always exercise caution in Human Services data analysis which goes to a second decimal place…people are trying to baffle you with precision when the precision is not warranted given the margin of error accepted and expected in this type of analysis and research.)
And let’s take a moment to examine the reverse of the formula…that if you prevent X from happening then Y won’t happen. Complex social issues tend to have more than one factor that needs to be considered. For example, homelessness is rarely caused by one event…it is the manifestation of several events over time (where sequence may be irrelevant) that destabilizes housing or the confluence of multiple factors during a single event. A reduction of focus to just one factor tries to over-simplify prevention activities and will likely result in more anecdotes than proof when trying to explain your efforts to prevent homelessness. (Look at this another way – we know lots about risk factors for homelessness and prevalent characteristics of chronically homeless people and families, yet to this day do not have a full-proof way of preventing homelessness because the cause and effect cannot be easily traced and applied to the unique circumstances of different households.)
In Human Services in particular – although applicable to any organization with inter-personal interaction – I strongly urge people to look for meaning and explanation beyond just the sequence of events. Dig deeper. Look at context. Examine a range of rational factors that may have had an influence. Then draw together the plausible narrative of why things are the way that they are.
Dealing with C.R.A.P.
Want to make the world a better place? Want your organization to run more smoothly? Want to change the way people view their community or work environment? Be prepared for CRAP. CRAP = Criticism, Rejection, Assholes and Pressure
Criticism…talk about a gift for people who believe it is better to give than to receive! One observation I have from the field and working with dozens upon dozens of communities – if you are being innovative people will ask what your evidence-base is; if you are drawing upon an evidence-base people will challenge whether that evidence rings true locally and will challenge you to be innovative. We need to balance innovation and evidence-informed service delivery. We need data to defend criticism from uninformed outsiders, but also be open to criticizing ourselves in the spirit of improvement. Criticism is normal. A bunch of “yes people” do not advance ideas or improvement. About the only type of criticisms that I reject are unsolicited ones based upon uninformed opinion and vague criticism that I don’t know how to interpret or put into actionable improvement.
Rejection…often seen as the flipside of acceptance, one of the toughest lessons in my professional career has been not taking rejection personally. I have confused rejection with ostracism. Rejection happens both passively and actively…the former keeping me up at night and the latter sometimes raising my “fight or flight” response. I have come to expect that people will reject new ideas or even proven ideas if it collides with their worldview. So, to address the possibility of rejection I have learned more and more about how the introduction of an idea –new or old – is sometimes more important than the idea itself if we want people to have openness to the experience of a new idea. Sometimes this means being a straight shooter, rather provocative, with some charisma and perhaps even some bravado. Other times it can mean patience, soft spoken and almost apologetic introduction of an idea or facts. Other times still it is a big room full of people where there are more likely to be some kindred spirits, whereas other times it is a small kitchen table trying to pull together a small coalition of like-minded people. Situational awareness and emotional intelligence is so key for creating an environment where rejection is less likely.
Assholes…so many ways to use this category. First off, I recommend taking Bob Sutton’s “Asshole Rating Self Exam (ARSE)” for insight and perhaps comic relief, though I think it is spot on in many respects. You can also take a gander at Cracked’s “5 Scientific Reasons Why People Act Like Assholes” which is also illuminating. The biggest assholes I have had to deal with are “professional” controversialists. I find it maddening when their polemical assertions are pointed in the wrong direction. How many times do I have to deal with being seen as evil because I helped a homeless person access housing (that is sustainable) but couldn’t solve their poverty? Was being poor and homeless better than poor and housed? Sigh. Also on my butthole list (in no particular order) are: people who create data or misinterpret data to “prove” their point; people who constantly interject without listening; people who degrade homeless persons; other consultants that are so competitive they spend most of their time putting others down; people who hurt children or puppies; men who beat their significant other; people that cut in front of me in line or in traffic; people who constantly rant on Facebook; okay – I will stop here.
Pressure…careful what you ask for rings true when I think of pressure. If you are successful, people can want you to be even more successful. Go the extra mile to meet deadlines to impact change? People may expect you to run a marathon weekly – or even daily. Finally got the public/media attention that you wanted for your issue? Now you will find yourself potentially the spokesperson for everything. Prepared an awesome presentation to explain a complex issue? You can feel the pressure to re-work other people’s presentations…become known as the “presentation guru”. Answer your work phone in the evening when clients call? You may feel the pressure to be “on” 24/7. You get the point. Pressure can start external, but it is when we internalize that pressure it can consume us…burn us out…diminish our desire to make positive change happen. Positive tension is a good thing in most instances, so holding things in balance is key to success.
CRAP happens. If you are prepared for it, you can ride the wave and even use it to your advantage. If you let it consume you, you will find yourself buried and unhappy – and less likely to want to affect change. Some tips:
Spend time thinking about how you are likely going to be criticized in advance of launching your new approach.
Be open to feedback – even critical feedback – when it is provided in the spirit of improvement.
Think of the best ways to get your ideas across – new or old – depending on the audience at hand.
Practice a variety of approaches of generating support for the same subject matter.
Don’t respond to assholes…their quest is to tear down without a solution focus. Investing your time with them only legitimizes their assertions.
Determine when and how you will respond to external pressures so that you can still exercise appropriate self care.
Health Needs and Permanent Supportive Housing
Do all chronically homeless people have health issues requiring permanent supportive housing? No. But the design and delivery of PSH needs to heed the health needs of chronically homeless people, while avoiding the pitfalls of a solely medical model in service delivery.
Homeless individuals have poorer health than the general population[1]. However, these individuals with poor physical and mental health and substance use issues can achieve stable housing[2]. Research from Toronto indicates that 72% of people in a Housing First program report improved physical health once moved into housing; however, while people with longer-term homelessness were likely to report improvements in mental health after moving into scattered-site housing with supports, they were less likely to report improvements in physical health[3].
There are statistically significant differences in self-reported physical health and self-reported mental health amongst homeless people, with homeless people fairing worse than the general population[4]. Length of homelessness has a direct link to the severity of the health issues, with people experiencing homelessness 5 or more years much more likely to have chronic health issues, and multiple chronic health issues much more prevalent amongst those homeless for a long time[5]. This would seem to suggest that PSH should first focus on those that have been homeless for longer periods of time with co-occurring health issues rather than focusing solely on health issues in the assessment.
The various types of specific health issues confronted by homeless people are numerous. For example, cardiovascular disease is more frequent than the general population[6], and can be compounded by the high propensity of cigarette smokers (almost 9 out of 10 according to self-reports) within the homeless population. Serious health conditions found to be statistically significant in difference from the general population include: Heart Disease (5 times greater than the general population), Diabetes (2 times greater than the general population), Arthritis or Rheumatism (3 times greater than the general population), Epilepsy (20 times more likely than the general population), Liver Disease, Hepatitis C (30 times greater than the general population), Hepatitis B, Cancer (4 times greater than the general population), Stomach or Intestinal Ulcers, Allergies (other than food allergies), and Migraines[7].
Tolomiczenko and Goering almost 25 years ago demonstrated that mental illness does not usually cause homelessness[8]. While not a precipitating factor, it can be exacerbated by the experience of homelessness. Stereotypes of the homeless population infiltrated with high rates of psychosis like schizophrenia are unfounded. While there will always be a smaller percentage of homeless people that experience schizophrenia – 6% lifetime prevalence amongst the homeless population in Canada and 10-13% found amongst rigorous US studies[9], the truth is that depression and anxiety disorders with alarming rates of suicidal ideation and suicide attempts are more common[10].
The costs and service use impacts of mental illness on emergency rooms amongst homeless persons, however, warrants attention. According to CIHI more than 50% of emergency room visits and hospitalizations amongst homeless people in any given year are a result of mental illness[11]. Given reported improvements in mental health and wellness after a housing intervention in Housing First[12], emphasis on housing is warranted to decrease these expensive health utilization costs to address compromised mental wellness experienced while homeless.
There is a high rate of brain injury amongst homeless people[13], but interestingly this often happens younger in life and predates their homelessness – as high as 58% amongst homeless men and 42% amongst homeless women[14]. Recent research on youth homelessness has also demonstrated that more than 50% of youth that experience homelessness have experienced a brain injury[15]. Given cognitive limitations and issues with impulse control that happen amongst people with brain injuries, different housing models can be necessary within PSH to provide a supportive environment that is attuned to the behaviours that these conditions may present.
Frequency of alcohol use and abstinence rates are not particularly dissimilar between the homeless and non-homeless populations[16]. However, instances of heavy drinking (5 or more drinks on one occasion) and rates of substance addiction are higher amongst the homeless population, as is the consumption of non-beverage alcohol where almost 10% of the homeless population uses daily[17]. Problems with alcohol use disorders are between 6-7 times more prevalent amongst the homeless population, and especially prevalent amongst homeless men where upwards of 60% will have an alcohol use disorder[18]. Use of tobacco is prevalent in almost 90% of the homeless population compared to 18% of the general population[19], which also needs to be taken into account when designing housing and service options – a rate that is most likely going to remain high even with the availability of cessation programs. While it is difficult to accurately and comprehensively quantify the depth and breadth of the use of other drugs amongst the homeless population (illicit drugs), US research from a couple of decades ago found the median prevalence of drug use disorders to be 30%[20]. The “drug of choice” within the homeless population is usually influenced by geography and ebbs and flows in popularity relative to availability and price. It would seem, however, that for several decades alcohol (including non-palatable alcohol), crack cocaine, marijuana, oxy and methamphetamine have been popular. Given the propensity for mental illness and substance use disorders to happen concurrently, it is important for PSH to take this into consideration. Moreover, given the rate of substance use there is a compelling case for PSH to embrace a harm reduction framework relative to substance use – neither condoning nor supporting, but accepting the rate of use as fact and commonplace.
Overall, mortality rates are much higher amongst homeless people than the general population. For example, a study from the late 1990s showed homeless youth in Montreal have a mortality rate 9 times higher for males and 31 times higher for women than other youth in Quebec[21]. A frequently cited study by Dr. Stephen Hwang[22], demonstrates that amongst the shelter using population in Toronto that mortality rates are 8.3 times higher than the mean for 18-24 year olds; 3.7 times higher than the mean for 25-44 year olds; and, 2.3 times higher than the mean for 45-64 year olds. Higher mortality rates and advanced ageing can be improved upon through PSH that offers safety and security to its residents with access to care that people may have been unable to access while homeless…or at least not sustainably or proactively or intensely access while homeless.
It is important to consider that street homeless individuals (sometimes referred to as “rough sleepers”) have poorer health than their shelter-using peers[23]. It is amongst the street homeless population that there is a greater incidence of chronic homelessness. Offers of PSH must keep this in mind in some respects when considering prospective tenants. If PSH looks solely to shelter environments it will likely miss some clients that would most benefit from what is being offered. Links between PSH and street outreach can be very important and effective in service delivery.
But health isn’t the only consideration. We don’t want PSH to become parallel health care providers to the mainstream health services. Health services, however, should be integrated as part of the service delivery, not the sole focus of service delivery. A more holistic view that also encompasses the need for the likes of meaningful daily activities, social networks, self care, avoidance of high risk and exploitive situations, etc are also beneficial in a PSH environment for it to be as health as possible.
[1] See for example: Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health; Hwang, SW. “The health and housing in transition study.” International Journal of Public Health. 011 Dec;56(6):609-23. Epub 2011 Aug 20; Wilkens, R et al. “Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study.” British Medical Journal. 2009 Oct 26;339; Tolomiczenko G. et al “Multidimensional social support and the health of homeless individuals.” Journal of Urban Health. 2009 Sep;86(5):791-803; Dunn JR et al. “Housing as a socio-economic determinant of health: findings of a national needs, gaps and opportunities assessment.” Canadian Journal of Public Health. 2006 Sep-Oct; Hwang SW et al. “Interventions to improve the health of the homeless: a systematic review.” American Journal of Preventive Medicine. 2005 Nov;29(4):311-9.
[2] Hwang, SW et al. “Health status, quality of life, residential stability, substance use, and health care utilization among adults applying to a supportive housing program”. Journal of Urban Health. 2011 Dec; 88(6):1076-90; Raine L and T Marcellin. “What Housing First Means” City of Toronto, 2007.
[3] Raine L and T Marcellin. “What Housing First Means” City of Toronto, 2007.
[4] Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.
[5] Ibid.
[6] Marmot M. and Wilkinson R. Eds. 2003. Social Determinants of health: the solid facts. 2nd edition. Copenhagen: World Health Organization (WHO); Frankish CJ, et al 2005. Homelessness and health in Canada: research lessons and priorities. Canadian Journal of Public Health. 96(Supplement 2):S23-S29.
[7] Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.
[8] Tolomiczenko G, Goering P. 1998. Pathways into homelessness: Broadening the perspective. Psychiatry Rounds. 2(8). Toronto: Centre for Addiction and Mental Health.
[9] Mental Health Policy Research Group. Mental illness and pathways into homelessness: proceedings and recommendations. Toronto: Canadian Mental Health Association; 1998; Fischer PJ WR Breakey. The epidemiology of alcohol, drug, and mental disorders among homeless persons. American Psychology 1991;46:1115-28.
[10] Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.
[11] Canadian Institute for Health and Information. (August, 2007). Improving the Health of Canadians: Mental Health and Homelessness.
[12] Raine, L and T Marcellin. What Housing First Means. City of Toronto, 2007.
[13] Highley, JL. Traumatic Brain Injury Amongst Homeless Persons. National Health Care for the Homeless Council. 2008.
[14] Hwang SW et al. “The effect of traumatic brain injury on the health of homeless people.” Canadian Medical Association Journal, 2008; 179: 779-784.
[15] Forchuk, C et al. Service Preferences of Homeless Youth with Mental Illness. University of Western Ontario, 2012.
[16] Health Canada. Canada Alcohol and Drug Use Monitoring Survey. Ottawa, 2011. Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.
[17] Raine, L and T Marcellin. What Housing First Means. City of Toronto, 2007; Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.
[18] Fischer PJ WR Breakey. The epidemiology of alcohol, drug, and mental disorders among homeless persons. American Psychology 1991;46:1115-28.
[19] Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.
[20] Lehman AF and DS Cordray. Prevalence of alcohol, drug, and mental disorders among the homeless. Contemporary Drug Problems 1993;20:355-83.
[21] Roy E, et al. Mortality among street youth. Lancet 1998;352:32.
[22] Hwang SW. Mortality among men using homeless shelters in Toronto, Ontario. Journal of the American Medical Association 2000:283:2152-7
[23] Gelberg L and LS Linn. Assessing the physical health of homeless adults. Journal of the American Medical Association 1989;262:1973-9.
The Difference Between That Which We Think and That Which We Know Is One of the Most Important Distinctions To Be Made
Kathryn Schulz is a “wrongologist”, with a stellar ability to explain why we shouldn’t regret regret and provides some very credible and compelling thoughts on being wrong. I am a fan. Her bookBeing Wrong: Adventures in the Margin of Error is a terrific read and if you have never seen her TED talks, I recommend both. One of her quotes which I have used over and over again because of the brilliance of it is, “The miracle of your mind isn’t that you can see the world as it is. It’s that you can see the world as it isn’t.”
People make mistakes. They should. Theories need to be tested and will frequently be wrong or prove something unintended. Being wrong doesn’t make someone a bad person. Being wrong, however, can hinder our ability to be better at our jobs and in our lives when we fail to make distinctions between what we think – sometimes are beliefs not backed up by facts – and what weknow – things that can be proven.
Over the past couple of decades being engaged with various social justice initiatives I have seen evidence over and over again that what we think is often different than what we know. The difference manifests itself in a couple of problematic ways. For one, there is a tendency to ignore knowledge when it flies in the face of what we think – on a personal, community or organizational level. For example, there is still a large group of people that think addiction is a personal flaw when we know it is a disease. People don’t make a conscious choice to have an addiction. And like any disease, people will respond different to treatment options (think of how different people respond to cancer treatments), have different perspectives on wellness and may or may not be ready for the life changes required to tackle the disease (think of someone with unmanaged diabetes).
On the flipside, once we know something there is a tendency to stop thinking about it and ignore opportunities for improvement. Take an example from your own life…you know Friday is garbage day so you stop thinking “What day is garbage day?” It is routine knowledge. The bigger flaw is when you stop thinking about things like “What can I do to make garbage day less arduous on Thursday nights or rushed on Friday mornings.” Or maybe your thinking leads you to questions like, “How can I reduce the amount of garbage my family creates?” In my professional life, I know for certain because of compelling evidence that people do better in housing than while homeless, but I need to keep thinking about how to make the experience of housing better for previously homeless people.
A lot of time people who are passionately trying to make their world a better place one person or family at a time are so busy doing that they fail to take time for thinking or knowing. They are so ingrained in routine without critical thought or discourse that they miss opportunities for professional development, personal growth and the ability to work and function in a true learning culture.
One of the tasks I love performing in my job is helping to develop emerging leaders and improving management practices within organizations. High performing organizations have been proven time and again to get better outputs, improved long-term outcomes, enhanced employees satisfaction, enhanced satisfaction reported from service users and less turnover within the organization. As part of that training, I use the table below with the leaders and managers within the organization.
Behavior% of Actual Time Spent on Activity% of Time Ideally Spent on ActivityInforming Clarifying Directing Persuading Collaborating Brainstorming/Envisioning Quiet Time for Thinking Observing Disciplining Resolving Internal Conflicts Praising/ Encouraging Learning/Improving Knowledge Base
Time and again I find it interesting that many are spending 0% Thinking or Improving their Knowledge Base currently and put little importance on it in the ideal situation as well. It is my contention that “leaderfull” cultures embrace the importance of spending time both thinking and knowing. Senior managers, Board of Directors, Funders and Government Officials involved in program delivery need to value both thinking and knowing within organization and encourage people to take the time to do both. It doesn’t take away from doing. It makes the doing better.
Perhaps your experience is like mine – there are some very divergent (and dare I say misguided) thoughts about how best to address complex social issues. It is good to have hypotheses, but these have to be tested and positioned within a knowledge base to have merit in implementation and long-term impact. Remember that once upon a time people thought that things like blood letting were standard for a range of medical conditions, that mental illness was once thought to be demonic possession in some people, that the earth was flat, that the universe revolved around the earth, that drinking milk or wine would help people overcome the plague, and so on. These were all strong thoughts that translated into beliefs that existed for quite some time before weknew better.
And there are some thoughts that will remain in a state of flux because there isn’t an overwhelming knowledge base that is irrefutable and people’s beliefs can take the place of knowledge. The economy is one field in particular where this is abundantly the case…one need not look further that the various views on matters like taxation or social spending.
Knowledge requires acquaintance with facts, truths, or principles, as from study or investigation. At the core of knowledge is whether or not the information is indisputable. While one would hope that knowledge helps inform the train of thought that people have on a particular subject matter, it can be difficult for knowledge to trump personal beliefs. If ignorance is bliss, some people are downright orgasmic in avoiding facts.
In my keynote speaking, public addresses, media interviews and training there are certain pieces of knowledge that I draw upon frequently because I know it can collide with what many people in the room may think:
Most chronically homeless people want housing. How do I know this? I have been part of three research studies that have asked chronically homeless people this question. Overwhelmingly, they report that they want housing. This flies in the face of a thought that people overwhelmingly choose to be homeless as a “lifestyle”. The small percentage of homeless people in these three studies that reported that they did not want housing? Well, for many of them it was because a service provider told them they were not “housing ready”. I think it is unlikely the same service provider asked them if they were “homeless ready”.
Sobriety is not a precondition for housing success. How do I know this? Because the majority of the people in the Western World consume alcohol or other drugs and never experience homelessness. Sobriety isn’t a condition for housing success for people with substance abuse disorders either. How do I know this? Because most people with addictions to alcohol or other drugs will never experience homelessness either.
People who are meant to feel poor will spend more on lottery tickets, which in turn can actually increase their economic poverty. How do I know this? I can point to work done by the Chicago Reporter that points to lottery spending by zip code which found overwhelmingly that people in economically poorer zip codes spent more on the lottery without returns that got them out of poverty. I can also point to the study published by the Journal of Risk and Uncertainty that proved that people feeling economically poor were more likely to spend more on lottery tickets.
People who feel poor do not make more impulse purchases of big ticket items than the rest of society. How do I know this? Research shows the impulse control to buy things like a new flat screen TV or laptop or whatever is the same as the rest of society – it just has a much larger impact on their overall financial health and can place their housing at risk. But they are not worse at making choices than the rest of us. Higher income earners, however, can buffer the impact of the impulse better without putting as much risk on housing or other life necessities.
Economically poor people are amazing at budgeting money and getting by each month. How do I know this? While economic poverty can place people’s housing stability at risk, the truth is that most people with very low incomes never experience homelessness. Consider the millions of people that live below the Poverty Line or Low Income Cut Off in North America that scrape by month after month.
Those are just a few morsels. I’m not going to give away all my juicy tidbits in this blog. But one can hopefully see how knowledge can challenge some thoughts that may or may not be true.
He may have taken a ribbing for it in the media and late night talk shows – and the context and pretense for which the statement was made may be challenged by some – but Former Defense Secretary Rumsfeld was making an important and true statement when he said,
“There are known knowns; there are things we know we know.
We also know there are known unknowns; that is to say we know there are some things we do not know.
But there are also unknown unknowns – there are things we do not know we don’t know.”
The “known knowns” are things we need to celebrate in our practice of Human Service delivery. And while we can prove that certain approaches work better than others – that may be based on anecdotes or a sample size of one rather than rigorous study – we should still be thinking about how to make the things we know better.
When we know there are some things that we do not know, we should spend more time thinking and analyzing the situation. We may look to other fields of knowledge. We may set up tests to engage in discovery. We should remain thirsty for knowledge about the things we do not know enough (or anything) about when it comes to improving practice.
And there will always be things that we don’t know we don’t know. Until we have the opportunity for discovery, the knowledge won’t be presented to us in a way that we can understand or use in practice. If we are truly operating in a learning environment, however, we will be better able to detect when a lesson is present for the learning.
I hope you will keep thinking about how to make your work better, using knowledge as best as possible, but not confusing what you think may be true with what is actually true when there is evidence to the contrary. I hope you will be open to learning new knowledge and applying it in your work, even if it flies in the face of what you have thought or practiced for years. And I hope you will remain committed to contributing to the field so that we have an ever expanding body of knowledge to be nourished by to make the experience of service recipients better. We can’t be afraid to be wrong – we must embrace it; but we can’t be fooled into seeing or believing something that isn’t actually supported by knowledge.