By David Bornstein
Jan. 16, 2019
First of two articles
The intertwined challenges that many people face might be addressed more effectively together than separately.
In the opening paragraph of “The Wealth of Nations,” Adam Smith observed, “The greatest improvement in the productive powers” of mankind come from the “division of labor.” Smith’s idea and his famous illustration — a pin factory that could increase its production hundreds- or thousands-fold via specialization — helped inspire the Industrial Revolution, informed the automobile assembly line and remains in play around the world, from factories that print semiconductors by the billions to surgeons who repair cataracts in minutes.
But the division of labor has fallen short when it comes to social problems. Over the past two generations, pin-factory-style specialization in social services has sought to help people facing an array of social challenges, including poverty, mental illness, homelessness, addiction, violence and trauma. All too often, these efforts meet with disappointing results.
Helping people flourish in the 21st century may require a reintegration of labor. Indeed, one of the most promising frameworks emerging is the concept of “well-being.” Around the globe, from Bhutan to Britain to New Zealand, a holistic well-being framework is beginning to taking root.
Well-being addresses a complex set of needs and experiences. So one big question is: What does it mean to translate this framework into practice, especially within the constraints of public systems? Next week, a second article will look at that question.
The focus of this essay is on the problems created when we try to meet human needs with isolated services. One group that has explored this question extensively is the Full Frame Initiative, based in western Massachusetts. It is advancing a well-being approach with major partners that include five state agencies in Massachusetts that are integrating anti-violence and housing services, as well as Missouri’s juvenile justice and child welfare systems and St. Louis’s family courts.
The Full Frame Initiative was founded in 2009 by Katya Fels Smyth after she spent over a decade running On the Rise, an organization that she had founded in Cambridge, Mass., to assist women facing homelessness, trauma and crisis.
“My ‘aha,’” Smyth recalled, “was that I saw that what is driving cycles of poverty, violence and trauma is, in part, that we focus on short-term fixes that undermine people’s long-term well-being. And what I mean by well-being is the set of needs and experiences everybody shares for health and hope. In order to get short-term forward movement on a problem, we ask the people who have the fewest well-being assets to give up some of them.”
Consider the case of Lola, who became a member of On the Rise’s community after having lived on the streets for years. She had fallen out with her family and had stopped taking her anti-psychotic medication — in large part because she felt the side effects compromised her ability to stay safe on the streets.
Smyth’s team helped Lola move into transitional housing at a local YWCA. She lived there for nearly two years. During that time, Lola reconnected with her family, became active in the Y community and resumed taking her medication. “She became kind of the queen bee,” Ms. Smyth said. “She was taking newcomers under her wing. People counted on her.”
Then Lola got lucky. Her number on a waiting list for government-subsidized housing came up, and she moved into her own apartment.
Within months, she was back living on the street.
“At the Y, Lola had a purpose,” Smyth said. “The staff counted on her to show new people around. It was close to the things that she needed. She could get to her medical appointments pretty easily. She felt safe there because not only was she known, but there were people around.”
“We didn’t pay attention to that,” Smyth said. “She didn’t pay attention to that. We were so busy celebrating her housing.”
From her experiences running On the Rise, examining effective programs around the country and collaborating with Dr. Lisa Goodman, a professor at Boston College who focuses on the intersection of poverty, mental health and intimate partner violence, Smyth began to see a pattern. When social services helped people achieve positive, sustained changes, it was because they attended to an array of core needs together, not separately.
Conversely, when services failed, it was because they forced people to make trade-offs: to give up something of vital importance.
Over time, Smyth refined her analysis to delineate five domains of well-being. She summarized them: “Social connectedness — who you depend on and who depends on you, and having a feeling of belonging; safety — when we can express core parts of our identity without harm or shame; mastery — the sense that we have influence over our future and have the skills to navigate life; meaningful access to relevant resources — the ability to meet our core needs in ways that aren’t dangerous or shaming; and stability — having things we can count on to be the same day to day, and knowing that a small bump won’t set off a crisis.”
“These drives are hard wired” in everyone, she added. “If we’re going to pit human services against 40,000 years of evolution, evolution will win every time.”
In the “full frame” model, what might look to a traditional case worker as resistance or noncompliance or backsliding can be seen, by contrast, to result from a system that is forcing an unsustainable trade-off on a client who is already in a fragile situation, or even a compliance with a higher sense of self than the case worker imagines.
For Lola, the benefits of having her own apartment were outweighed by the loss of the sense of belonging, purpose, stability and social connectedness that she had experienced at the Y.
“Lola made it back into housing,” Smyth said. “But here’s what I wish we had done the first time: Celebrate the housing, but say, ‘Let’s think about what you’re going to have to leave behind and see if we can minimize that so that the change is actually worth it to you.’”
What might that have meant in practice? Perhaps the Y could have offered to buy Lola a bus pass if she agreed to return a day or two each week to lead new groups. She would have stayed connected to her community and maintained that all-important sense of purpose, and she could have scheduled her medical appointments on days when she was in the area.
What inhibits this kind of creative problem-solving from emerging more often in systems?
One thing is a mental trap that psychologists call the “fundamental attribution error.” Stated simply, when strangers do things that we see as negative, we tend to attribute it to their characters rather than their circumstances. (By contrast, when we, or people we like, fall short, we tend to attribute it to circumstances.) People living in poverty or dealing with violence or addiction are often seen as “fundamentally different,” Smyth says, or as broken or deficient and therefore in need of being fixed.
To work around the fundamental attribution error, it’s essential to get nuanced information about people’s situations. Next week’s article will examine how the Full Frame Initiative has helped the St. Louis County Family Court simplify its approach to assessment — focusing on the kind of information that is needed to recognize the role of circumstances and understanding how court officers can avoid inadvertently forcing youths or families into unsustainable trade-offs.
Another problem is that systems deal with problems in sequence, rather than in an integrated fashion. For instance, when a woman seeks assistance for domestic violence, the initial focus is usually entirely on safety for her and her children. “People experiencing domestic violence are often told by child welfare workers that they need to leave their partner or risk losing custody of their kids,” Smyth said.
That might seem to make perfect sense. Who can argue with safety first? But other things matter, too. Case workers report a spike in intake for domestic violence at the end of the school year because for many women, the trade-off of disrupting a child’s stability during school isn’t worth the perceived benefits of seeking help. But once school is out, the equation changes.
Smyth recalled the case of a mother who had been abused and who had a son on the autism spectrum. Finally, she found an aide in his school with whom he bonded.
After years of struggling with his disability, this woman’s son was finally doing well. It’s not that she wasn’t concerned about her safety, but she didn’t want to jeopardize his progress by moving to a shelter, which often entails changing schools.
“The case worker may be very compassionate, but she’s still going to push her to the shelter,” Smyth said. And that’s what happened to the mother. The thinking is additive. First, safety; then add services to deal with the trade-offs; then get the son into another program; then help the mother find a new job, and so on.
The result? The son moved to a new school and started to have behavior problems. The mother watched a year of good work with his aide unravel. So she returned home — not because she wanted to be back with her partner but because she couldn’t bear to watch her son lose what he had gained.
Back at the school, however, the aide was assigned to another child. “So she’s not back at square one,” Smyth said. “She’s at negative one. When I’ve shared this story, many advocates have told me it’s very familiar to them.”
“When you hear about programs that have some success, and then it drops off, it’s not about lack of motivation,” Smyth added. “It’s about trade-offs that are too big. People are incredibly motivated to get safe. A woman knows that being choked unconscious is unsafe. But this progress for her son is also incredibly valuable. So what she needs is for her case manager to help her figure out an alternative that holds that piece in place.”
Next week, I’ll explore how the Full Frame Initiative has been working with government agencies in Massachusetts and Missouri to do just that.