Our society is ageing, and the scale of our demographic challenge is immense. To choose just one of several striking projections, between now and 2050, the number of people over the age of eighty will triple to around eight million.
At some time in our lives, all of us will be faced with decisions to make about older people’s care, be it our own, or a loved one’s, whether it is in a professional, personal, or voluntary capacity. How will we make such decisions?
At some time in our lives, all of us will be faced with decisions to make about older people’s care
On reflection, the question is not so much about adult social care policies, but the complexity of choosing between different aspects of ‘care’ which often look very different from conventional models of state provision. The pertinent questions become: Who do we trust to help us make these decisions? What are the risks in making one choice as opposed to another? Should physical safety be prioritised above wellbeing and quality of life?
We explore many questions of this nature in our recently released evidence review: ‘Improving Decision-Making In the Care and Support of Older People: Exploring the Decision Ecology’.
Early this year, the Joseph Rowntree Foundation, as part of their Risk, Trust and Relationships in an Ageing Society programme of work, put out a call for a review of the evidence surrounding risk and trust in an ageing society. The RSA’s proposal was accepted, along with a contrasting but complementary proposal from a team at Brunel Institute for Ageing Studies. We focussed our evidence review using decision-making as a lens through which to explore the broader issues. The team from Brunel took a different approach, reviewing contrasting bodies of literature from disciplines including psychology, political philosophy and gerontology.
On Wednesday last week, the two evidence reviews were published at a launch event at Brunel University. I presented our review, and in preparing what I had to say, I found myself pleasantly surprised by the piece of work we produced.
The process of compiling the review involved several members of Staff from Social Brain and Connected Communities and was not the smoothest or easiest of processes. In all honesty, while we were fascinated by the content and relevance of the work, by the time the final draft was signed off, the process felt so protracted that I think we were all relieved to move on to other things.
So, when I came to talk to an interested audience about what we found, it was rewarding to discover that I felt confident in the value of the overall message of our evidence review. (More generally, it definitely helps to have a gap between completing a piece of work and launching it, which gives you time to appreciate the document as something you have produced, while being free from the gruelling process that produced it.)
The Decision Ecology
Our report paints a picture of the ‘decision ecology’. Jonathan Rowson coined this term to capture the complex social context in which decisions are made, including the diverse range of actors including the older person, their family, friends, neighbours, professional carers, health providers, volunteers, acquaintances and the community at large.
At the heart of this ecology is a triad, consisting of the older person, their informal carers and supporters (such as friends and family) and their formal carers (professionals and practitioners). Like any threesome, this triad is unstable, and the balance of decision-making power tends to be weighted towards the professionals and practitioners.
The insider knowledge that family members have about their older relatives is all too easily sidelined or overlooked, and professional ‘expertise’ takes pole position. The danger is that important personal preferences can be neglected, and decisions made to favour institutional or administrative convenience.
The insights of the Social Brain perspective tell us that the traditional view of decisions being made on the grounds of logic and rationale is at best inadequate. Decisions are still implicitly framed as individual, conscious and rational, but they rarely are. In reality they are influenced by affective, unconscious and social factors, including our cultural biases, negative stereotypes and risk aversion. Because of this, we need to think very carefully about whose perspective (or decisions) should be given precedence, and on what basis.
To make good decisions, it is vital that we build trust. There are various tools and strategies that can help us do this, and taking seriously and making space for personal narratives is one of them. The stories we hear and tell can change attitudes and be emancipatory and empowering. This emphasis on the unrecognised relevance of narrative was a key part of the report.
Challenging declinist stereotypes of ageing is part of our responsibility, along with being reflexively critical about our attitudes to risk.
Most importantly, we need to do everything we can to enable genuine partnerships between care providers, care recipients and their families and supporters. The responsibility for decision-making should be shared as equally as possible, and efforts made to include and respect everyone involved. Challenging declinist stereotypes of ageing is part of our responsibility in this, along with being reflexively critical about our attitudes to risk.
At some point in your life, perhaps quite soon, you will be playing a part in this decision ecology- it is worth reflecting now on what kind of part you want to play. You could do worse than start by reading our evidence review!
Earlier today I chaired an event on the virtues of procrastination with Professor Frank Partnoy, who was recently nicknamed ‘The God of ‘hang-on-a-minute’.
I will (he says like a true procrastinator) return with a more detailed blog on the subject soon, because I want to
until I can do the event (see photo) and the book justice. (There is great stuff about the timing of jokes and apologies, lots of decision theory, an analysis of discount rates, a constructive critique of Gladwell’s blink and much more- way too much to get into at the end of the working day).
(Image via bookandborrow.com)
We are accepting a quick answer when instead we should be asking a slow question.”
“To achieve great things, two things are needed: a plan, and not quite enough time” – Leonard Bernstein
“Never put off until tomorrow what can wait until the day after tomorrow.” – Mark Twain.
“Make sure you have finished your speaking before your audience has finished their listening” – Dorothy Sarnoff
There are also some really serious implications in the book for the major issues of our time, of which the following is a mere tease:
“Today virtually no politician…talks about replacing GDP in the long-term; instead everyone has zeroed in on how to increase GDP in the short term. We are accepting a quick answer when instead we should be asking a slow question.”
Just came across this section of Transforming Behaviour Change while looking for a reference about decision-making and thought it was worth sharing. Any vegetarians or anti-vegetarians out there with views on the subject?
“This message that we are not rational is not a simple one to convey, because we also appear to have a somewhat craven need for rationalisation. In fact, the social presumption of rationality is so strong that we are inclined to find and create reasons for our actions, or even invent them, merely to preserve the illusion that our choices are freely chosen.
This social imperative of cognitive consistency is the reason why vegetarians, for example, are frequently cross-examined, often by an entire dinner table, on the rationale and consistency of their preference to avoid the meat that most people eat. At an anecdotal level, it seems the ethical and environmental gains achieved through eating less meat are given relatively little attention, compared to the social sanction of highlighting perceived inconsistencies in the individuals making the effort.
For example, the inconsistency of wearing a leather belt while avoiding a beef stew appears to be more salient in social company than the fact that, for example, if every
American reduced meat intake by one meal a week, it would have the equivalent environmental impact as taking five million cars off the road.
In a recent talk on ‘Eating Animals’ at the RSA, Jonathan Saffron Foer argued that most meat eaters simply do not want to know about the conditions on factory farms, for fear that it would create unbearable cognitive dissonance. In light of animal suffering, and concomitant environmental degradation, Foer suggests people cannot reconcile their desire to enjoy the taste and cultural appropriateness of meat eating with their desire not to cause unnecessary suffering, so rather than stop eating meat, they prefer not to know about the suffering and the environmental harm:
“We have such a resistance to being hypocrites that we would rather be fully ignorant and fully forgetful all the time.”
This claim is a strong one, but it is important to make this case because it is fundamental to the social influence on decisions, and supports the need to shape social norms, rather than merely being subject to them, for it is these norms that norm-alise our behaviour.
A similar point about the challenge of pervasive self-justification is made by Tavris and Aronson, who contend that there are very few conscious hypocrites in the world. Indeed our capacity to rationalise our behaviour as being consistent with our beliefs is extraordinary, and we usually achieve this by shifting our beliefs rather than our behaviour, even if doing so paradoxically flies in the face of reason. As Tavris and Aronson put it:
“All of us, to preserve our belief that we are smart, will occasionally do dumb things. We can’t help it. We are wired that way.”
While preparing for your last holiday, how hard was it to pack your suitcase? Well, that probably depended on two things: the amount of stuff you wanted to bring, and the size of your suitcase. This is a wonderful analogy for many decision areas in life. For those of us trying to lose weight, the “stuff to pack” represents the amount and type of food we’d like to consume, and the suitcase represents the restricted calorie count of our diet plan. For those of us struggling with poverty, we must determine how to best cover our bills, grocery shopping, and other purchases, given our finite budget.
Referred to as combinatorial optimization problems in geek-speak, these ubiquitous problems arise when we are faced with many choices of things to “pack” and a fixed space in which to fit them. When our suitcases are large, or we have few things to pack, there is no problem – everything we need can easily fit into our large case and we may even have some spare space left over (for souvenirs!). But as soon as our demands grow or our suitcase shrinks, so that our requirements outweigh our allowance, trade-offs emerge. If I bring a beach towel, I don’t have room for my trainers. Or more critically, if I pay my water bill, there’s not enough left to buy new school clothes for my kids; if I pay off my credit card bill, I can’t afford to cover my rent or mortgage. Ultimately, the smaller the suitcase, the more complex the decision-making process of what to pack becomes.
Eldar Shafir of Princeton and Sendhil Mullainathan of Harvard University use the packing metaphor to explain why circumstances such as poverty, being time-poor, or being overweight seem to self-perpetuate. They argue that the very existence of scarcity of a given resource – be it money, time, or allowed calories- may impede “rational” decision-making. This is because the stress of managing the complexity of the packing problem effectively uses up some of our cognitive resources, such as attention and self-interest, which are required to reach optimal decisions.
In other words, the stress of having not enough money to meet my financial requirements may actually impair my ability to take a decision which could in turn help alleviate the situation. This insight is important, as it provides an alternative to the existing theories about the behaviour of the economically disadvantaged – one being that people in poverty are making rational decisions given the circumstances in which they find themselves, and another being that behaviour is driven by what some term a “’culture of poverty’ based on deviant values”. Instead, it may be that despite best intentions, complexity depletes our already limited stock of cognitive resources, and the mental effort required to choose the most lucrative option simply outweighs that stock.
It’s interesting to see how these situations can be self-reinforcing, using the thematic framework set out by the RSA’s Social Brain project. The RSA looks at attention, decisions, and habit as key components of behaviour change. First, the increased complexity associated with scarcity exhausts our stock of attention and self-control. This in turn affects our ability to make decisions and choose options which are in our own self-interest. Finally, habits may start to form based on this sub-optimal decision making. Once behaviour becomes habitual, it becomes more difficult to change. It is clear how slippery this slope may be.
A challenge is to find some potential solutions to mitigate the effect of the packing problem in the realm of personal finance. Could one be to make financial advisors more readily available, especially to those on low income or who are recently unemployed? A financial advisor or other external support may be able to help assess the situation with a fresh perspective, unencumbered by the stresses and cognitive strain of poverty. Have you seen instances in your own life where scarcity has made a noticeable difference to your decision making? If so, have you been able to tackle it – or has the “bad” decision now become habitual? Your insights may shed light on how to help lift some of us out of perpetual cycles of behaving against our own self-interest.
One of the main ideas to emerge from the Social Brain Steering group in year one of our project is that the dynamics of human behaviour are best captured in a three-part rather than two-part relationship.
We are not just a controlled system and an automatic system, in which our automatic and largely unconscious behaviours are supplemented and informed by occasional conscious deliberation. In fact our behaviour is mostly habitual.
Habits are important because they define who we are, but also because they can be changed. You breathe automatically, you see automatically, but you think, decide and act habitually. Confucius captures the point nicely when he says: ‘Men’s natures are alike; it is their habits that separate them.’
Habits are driven by our automatic (principally limbic) system, and often feel automatic due to the way our brains predict events, and reward us when those predications are accurate, principally through the release of the ‘feel good factor’ in the form of dopamine. But habits are acquired and conditioned behaviours rather than strictly automatic. They are second nature rather than first, and therefore amenable to the influence of deliberation and reflection.
However, no matter how much knowledge, reflection, and deliberation you bring to bare, you need behaviour to change behaviour. Thought alone will rarely change a habit, because willpower is scarce and depletable, and rarely sufficient to turn the thought into action on an ongoing basis.
Yet the right kind of thoughts can help you to outsmart your automatic system. By using whatever conscious control you have, you can change your environment, such that your automatic system is not given the fuel of familiarity, and your habitual behaviour is not repeatedly reinforced. ‘Nudge‘ therefore seeks to change what we do by shaping the environment to make best use of what we know about our automatic behaviour.
You can also free yourself from your habits to an extent by shifting your goals and expectations. In this respect, ‘Think‘ seeks to change our conscious thoughts, such that we change our sense of who we are and what we should want, and thereby recalibrate our habits by seeking out different kinds of reward.
The RSA Steer approach takes the best of both approaches. We seek to bring people’s conscious attention to the power and strength of automaticity,but we also respect the role of conscious deliberation. Changing habits is the main aim of this endeavour, which is one reason why the first principle of our Steer report is that ‘habit is king’.
We know a lot about how hard it is to change bad habits, but much less about how we form good habits. This asymmetry is perhaps in the process of changing, because a recent study authored by Phillippa Lally at UCL suggests that it takes about 66 days for a behaviour to become habitual, by which she means completed without thinking about it. Commentary on this finding can be found here and some ruminations about different numbers of days for different kinds of habits can be found here.
66 days? In other words it is not easy to form a good habit. You need repeated practice, and need to find a way to keep motivation high. As Canadian Magician Doug Henning once put it:
‘The hard must become habit. The habit must become easy. The easy must become beautiful.’