I was reminded by this recent piece by Dr Chris Johnstone over at ClimateCodeRed of the meeting that he and I held in June 2006 with Dr Stephen Rollnick. This was back when I was researching the Transition Handbook, and we met for a day to discuss how insights from the psychology of health behaviour change might be helpful when tackling environmental issues like climate change and peak oil. It was fascinating, and I realised as I read Chris’ article that I had never posted the transcript of that conversation here yet.  So here it is, slightly dated, but hopefully containing some insights you will find useful (it’s quite long!).  My thanks to Chris and Stephen for a fascinating day (nearly 6 years ago!). 

Hopkins.  Most of the people who write about peak oil come down to saying the only thing that will be an adequate response to it is something on the scale of a war time mobilisation.  A lot of people use that phrase – ‘a war time mobilisation’ – to get across the scale of what needs to happen in terms of pulling in all the different agencies, and industry and government and so on, towards this thing.  So that question of how we engage communities on a response of that scale is very much what fascinates me and it strikes me that over the last forty years, the approaches environmental organisations have taken just haven’t done it.

I was fumbling around thinking “How will we create the scale of engagement for a problem this big?” when all the tools we’ve had up to this point haven’t been sufficiently effective and won’t get that scale of response.  That’s what led me to looking at this whole addiction thing, because whether or not you can say society is addicted to oil, I think you can argue that society is dependant on oil. I found the Stages of Change model particularly interesting because of the insights it gave into why it is that if you go to a whole town and give them leaflets saying they should put solar panels on their roofs, only 2% of them actually do so, and the rest of them just actually won’t shift.

I’m thinking it’s probably not because they don’t care; then with the Motivational Interviewing approach, it struck me that here’s a tool to work with. Ambivalence is a huge problem on a societal scale – why don’t people do stuff?  They’ll plan in advance in terms of their children’s financial futures but not in terms of the climate or that kind of thing.  As far as I could see it, it had only really been used for individuals and groups, and I’m kind of intrigued. In designing this process we’re going to be starting in September called ‘Transition Town Totnes’, how might we use insights from Motivational Interviewing on a larger scale, and try and address that collective sense of ambivalence?

If you’ve got different stages of change, how do we best work with the people in these different stages?  Because, by my understanding, (and I’m only two months and two books in to all of this!), each of them needs handling in very different ways, and with a very different approach.  If you just go running in with a ‘one size fits all’ approach, then you might engage one third but the other two thirds are going to be more put off probably.  So how do we engage the people at those different stages?  How practically might we design approaches that would bring them on board?

Rollnick.  I think that was very carefully put because you talk about using insights from Motivational Interviewing – not the somewhat over-simplified notion of ‘I want to apply Motivational Interviewing to a community’, which could be one slightly over-simplified way of looking at it, and could plunge us in to discussion about the viability of an individual method based on empathic listening getting out into the social sphere with all sorts of issues to discuss and struggle to overcome, which I notice during the forum I started engaging with recently with Allan Zuckoff.  But you just talked about taking insights – trying to improve our understanding of the way people feel, and what’s the most constructive way of responding to it.  So I’m not wriggling with ethical itches, d’you know what I mean?  Whereas if you’d said ‘apply Motivational Interviewing to a community’ and ‘do MI on a community’, I’d be wriggling with itches.

Johnstone. What kind of itches?

Rollnick. Ethical itches, conceptual itches, maybe some practical itches, wondering how realistic the whole thing was, but certainly conceptual and ethical itches, of the kind that Alan wrote about in the forum.

Johnstone.  What I’m struck by are the different levels of the spirit of Motivational Interviewing and the techniques of Motivational Interviewing.  And the spirit of Motivational Interviewing, as I see it, is very much about not doing things on people to manipulate them in a particular way, but it’s somehow about clearing a space for people to be able to look at the complexity of how they feel about an issue.

It’s not just a case of ‘am I for it or am I against it?’  There are often different parts of people…part of them maybe for, part of them maybe against, part of them maybe unsure. When there is that complexity of different parts pulling and pushing in different ways, this can lead people to become stuck. So when you provide a space where people can look at what the pushes and pulls are within them – I find that enormously helpful.  What I also find enormously helpful, working say with people with severe alcohol problems, is when you’re in a space where it’s somehow okay to acknowledge that there are attractive things about drinking, you move out of the space of being the judge and the shamer, which tend to really close people down.

And so I think just applying that spirit and stance to environmental issues is a really good transfer, because quite often I see polarities developing, with one group of people saying ‘you should’ and waving a finger, and other people saying, ‘well, why should I?  That I’m being asked to give up things that are important to me – I’m being asked to give up aspects of my lifestyle that I find attractive.’  And so the people who are being seen as doing that are seen as somehow takers away of joy.  And that polarity is really a polarity that probably exists in all of us.  Certainly with me I acknowledge the part of me that is attracted to aspects of the Western lifestyle – I’m quite attracted to various gadgets; they have incredible utility and allow us to do things.

And the same time I look with horror sometimes at the way I see our culture going, when I read information about what’s happening with climate change.  So one of the things I really value about Motivational Interviewing is this idea of rather than the interviewer challenging the clients, they are holding a space where the challenge can occur within the client, in acknowledging their own mixed feelings.  And the stance is of really respecting their choice – it’s not about trying to get them to do something, but about when you open up a space where they can really look at what they’re doing, they can work out what they want to do themselves, or get clearer about that.

Rollnick.  And I don’t think I’ve got anything about MI to add to what Chris just said – it was all beautifully said and I agree with all of it.

Johnstone.  Thank you.

Rollnick.  Just beautifully put.  And trying to walk over a bridge to what you were talking about…we got in to this MI thing because we became disturbed to the extent to which people were being judged and shamed – to use Chris’s language.  How problems were being attributed to the people when in the relationship it was quite clear to Bill and I that we were part of that.  And since we were the experts and professionals, it’s not our job to pass judgement about lack of motivation in someone else, but to have a look at the way we were communicating in that.

I think that was the big thing for both of us, and we both had different sets of experiences as professionals, and before that in different situations in the addictions treatment field where we thought, ‘For god’s sake, this professionalized shaming and abusing people is not on.’  So our approach has been soft and therapeutic in the way we write, but that’s the passion that’s behind it. One clear bridge that’s over in to your world is shaming on a large scale, so if you make people feel bad they’re less likely to change.

Johnstone.  Yes, although I think I would qualify that because one of the strategies in Motivational Interviewing is to develop discrepancy (where someone is aware of a gap between their behaviour and their values) and when you do this you hold a space where people do feel uncomfortable. After a Motivational Interviewing session it’s possible that someone may feel more uncomfortable than they did at the beginning.  Perhaps it’s more about how you can hold a space that supports people to rise to the challenge created by that uncomfortable feeling.

I recognize there are different sides to this – one is acknowledging that feelings of discomfort can be motivating. But there was also something William Miller wrote and it’s something like, ‘When you have a discrepancy you can respond in different ways.  One is to change your behaviour and another is to change the information.’  So if you’re aware you’re behaving differently from how you’d like to, you can change what you’re doing, or you can also blank out the information that’s telling you you’re out of step with your values. My concern is that this is happening on a larger societal level.  Just thinking for example that Exxon-Mobil the oil company has spent millions of dollars funding public relations companies in America to try and block awareness of climate change issues.

This is very similar to what the tobacco industry did.  The tobacco industry pumped lots of money into saying that we need more research, that there’s still doubt about this issue, that it’s not something there’s universal agreement around yet.  First of all they did that with the evidence showing people smoking were getting ill, and then they did this with the evidence that people around those smoking were getting ill from passive smoking. The tobacco industry specifically targeted key pieces of research that showed the health risks of passive smoking in a way that created the impression of doubt when in fact there was much clearer agreement amongst scientists.

And I see a similar process happening with the climate change issue. Cultivating doubt keeps us collectively in the contemplation stage of change, rather than allowing us to move on to preparation and action.  While part of what’s needed here is awareness raising, I also find it useful to think about different levels of change…there’s raising awareness and there’s changing behaviour – but between those two there’s the big area about how we work with attitude shift and motivation shift and that’s really not down to what the information is but what it means to people.

Hopkins. Exactly.

Johnstone.  And if the information means, ‘My god, this is really scary and I can’t handle the distress created by this information’, that’s what leads to people shutting down.  This also happens in the addictions field…quite often I work alongside people who have to face completely ghastly information, like their children being taken away, or they’ve got advanced liver failure.  Sometimes that information by itself is too much to handle and people close down with it.  But if you can be alongside them in looking at what’s going on, you can support them in finding their courage to face things. I like the word ‘en-courage’.  When you encourage like this, you support people in finding their courage to face the stuff that’s unfaceable.  And I think that’s where some of the skills for motivational interviewing can be really helpfully applied.

Hopkins.  I did a talk at Schumacher College a while ago and Satish Kumar was there.  The talk I do has a little bit at the beginning about peak oil and what it is, but then it’s all about solutions.  At the end he said, ‘that was very good, very interesting, but you know, I do have a problem with you using fear to try and motivate people to do stuff.’  It was interesting and it got me thinking about the film The End of Suburbia, which is the classic way people get in to peak oil – have you seen that?

Rollnick.  I haven’t seen it, but I’ve seen it referred to.

Hopkins.  Okay.  For a lot of people…I’ve seen people really, really distressed by it – it’s a very intense film about what the impact of peak oil could be on society.  I’ve done lots of public screenings of it and a few times have had to sort of talk people down afterwards.  A lot of people go ‘yeah, fantastic!’, but some are quite distressed by it.  That sense of what you were just talking about, about breaking the news to people and how you best facilitate that.  There was the thing that Chris put me on to – the FRAMES Model – which I’ve used in the dissertation I’m doing as a thing to pull all the different strands together.

The way they talk about it as feedback in there is really good.  You’re presenting – rather than trying to terrify anybody – you’re presenting honest, clear feedback.  You know, ‘if you carry on drinking another six months you’re finished’, or actually, ‘this is where the world is at’.  The difference comes with what happens after this. If you just present that and just sort of walk off and leave them with it, that’s one of the things that closes people down. I saw James Lovelock speak a while ago, presenting a horrendous gloom and doom climate change scenario – ‘we’re all finished, there’s nothing any of you do when we leave this room tonight that can make any difference, humanity is completely finished.  We’re just talking about a sustained retreat to the poles’ I think that’s so irresponsible because where can you go with that?  You can’t do anything with that. You want to retreat when you hear that, don’t you?

What I very much try and do with my stuff is present feedback in the form of: ‘Here we are, this is peak oil, here are the scenarios, this is like the ghost of Christmas future in a sense, but how about we do this?  Actually it could be fantastic!  Actually by the end of this process our quality of life could be much better and we could be spending more time with our kids and have a garden full of carrots.  It could all be a much better process.’  In that sense I found that FRAMES Model really, really useful as a way of kind of bringing it all together.

Rollnick.  So we could be starting to clarify a number of principles of good practice in promoting change in health related issues on a large scale. On the train, I think I was half asleep when I started dreaming, and I started thinking, ‘Well where are there health concerns that affect a whole community?’…I thought about some aboriginal communities I’ve come across in Australia, settlements where everybody is pissed and addicted to alcohol.  Just a whole place is riddled with it.

There’s a San Bushman community I know of in the North West Cape that has a similar problem.  They happen to both be very socially deprived and devastated, with an explanation in their history, but the way they present right now is everybody sitting around pissed.  So they’re communities where there are clear concerns about peoples’ health and not too dissimilar because I’m sure you could articulate concerns about peoples’ health and well-being in this community or the world as a whole.  So I’m comfortable with the lack of ethical itches there.

Maybe because I’m working with the brief intervention health care, general hospital world, I’m used to trying to pull out some simple guidelines.  There could be principles that come out of what we’re talking about and there are some principles that are coming out.  One’s got to do with how you’re handling information, and how you conceptualise the process of informing people.

Johnstone. I’m picking up there are potential side-effects to the way we present information. We can present the same information in three different ways and have three different consequences, and we need to be aware of the potential for overwhelm and close down when giving bad news.  If we are aware of that then we can think of information giving as having different phases to it.

Whatever news we hear in our head, it has to be digested down to the heart level to really take effect. Digestion involves exploring the meaning component of information – what does it mean to me?  What are the consequences?  And there’s a feeling response to that. Information has to be digested at different levels and if we’re aware of that digestion process, then perhaps we may not give quite so much information all at once, but give it in digestible chunks, and pay attention to the digestion process.

Rollnick.  The word ‘digestion’ is lovely there.  We’ve sort of agreed that hitting people crudely with a whole load of bad news, like that lecture you described, can reinforce shut down a lot of the time. So time and space to digest is needed.

Thinking just about information for a moment – I think another principle we need to get back to is how you deal with discomfort, with people actually feeling it.  And it goes beyond information exchange, it’s a deeper process.  We need to hit that principle somehow in some constructive way.  But just on the information exchange issue – that might be another principle, that it should have to do with exchange rather than dumping.  And dumping fearful information doesn’t lead to behaviour change, especially fearful information that makes you feel ashamed or shut down. We know that in health care.

The renal consultant said to me the other day, ‘Steve, we need help with communication training on the ward.’  So I go down and say, ‘What’s the problem?’  He says, ‘They just will not reduce their fluid intake to below a litre a day, and we’ve got the evidence’, because I think they were on dialysis or something… ‘and we actually say to them, look we’ve got the evidence that you’re not restricting your fluid intake. Can you imagine the shaming that’s going on?  ‘We’ve got the evidence that you’re not doing this, and they’re just in denial.

We need communication training to get through their denial.  And I tell you Steve, shall I give you an example?  They’re in such levels of denial – you tell them that if they drink more than that they’re going to die, and guess what happens Steve?  They die.’  That’s how bad their denial is, you know, and if you can imagine what I’m thinking – ‘Man! The way you’re handling information giving – it’s not exchange, it’s dumping! It’s all the things that we know are going to close people down.

But what I found very useful, this is 15, 20 years ago, about these drinkers’ check up studies that Bill did, because they were the first publications on MI that were sort of, of an empirical nature – and he puts these ads in the newspaper that say ‘Are you troubled by your drinking?’, and these folk would come in.

And one group got standard feedback – ‘If you don’t do this, then this, then this…’, variation on soft shaming I would have thought, dumping information, you can see lots of things…as opposed to what he described as MI.  I’m trying to unpack what was actually going on in the process, and it wasn’t just the empathic listening, which was there.  It was making a distinction between information and the interpretation of it.  So I picked that up and I’ve been trying to train healthcare practitioners to consider that distinction.

People have often said to me, ‘But hang on, how can you distinguish between facts and their interpretation?  What’s a fact?’  And I think that’s potentially pedantic because if you allow some blurred boundaries I still think the distinction’s useful.  The job of the practitioner is to present an exchange, present the facts, all the information.  And then their task is to elicit the personal interpretation from the person, so that you’re giving them a chance to personally digest, obviously.  And then you can take them to an empathic atmosphere and many of the qualities of constructive change that Chris has been talking about can take place.  You can pass judgements on how is this person going, – do they need more information?  Are they heading for shutdown?  And all that…So getting over to the bridge, getting over the bridge to your world, distinguishing between the facts and their interpretation and encouraging people to make the interpretations for themselves, maximises digestion.  How’s that?  Do you see what I mean?

Johnstone.  This is really good because this picks up from what you were saying in terms of how Motivational Interviewing developed where you and Bill were acknowledging the impact of the way you give information. When you’re looking at the phenomenon of resistance, rather than blaming them for being resistant clients who are unmotivated, you’re acknowledging that actually you can influence the degree to which they become resistant.  It’s not the whole story, but you are part of a story, and if you’re part of the story, if you can find out what part you can play in that, then you can start doing the opposite of what would create resistance.

I think this is where the ecological movement can really learn – it’s like saying, well actually the way information is presented will have an impact on how resistant people are, and we could be doing things in a way that’s making people more resistant and increasing polarization. If we were to design a campaign that would really turn people off, and if it was to have an opposite effect of what we want, one of the things we would do is present lots of information all at once in a way that was overwhelming, frightening, and then we would blame people for it: ‘This is awful and it’s your fault.’

Rollnick.  And you’d mix up information and peoples’ interpretation of it, you’d confuse the two, you’d lump it all together.

Johnstone.  Or you’d be even telling people what their interpretation should be rather that finding out what it is.

Rollnick.  So you’re kind of saying ‘Here’s a graph that does this – isn’t that scary?’   ‘You should be scared’, or ‘I’m telling you that you are scared’. Yet people react in different ways and sometimes there is a lot of fear, sometimes there is despair, sometimes there’s enormous guilt, but sometimes there isn’t.  Sometimes there’s a sense of ‘What’s that got to do with me?  I’m probably not going to be around when that’s happening anyway.’  Or that sense of the kind of nihilism of ‘I already know this and I don’t need to be told.’

Johnstone.  I remember I did a training session with someone who was working in a hospice, so it was about how to communicate information about peoples’ prognosis with cancer.  And he was saying, ‘Well, sometimes people do want to know, but it’s a bit like if you’re overdrawn, you don’t need a letter from your bank manager every day telling you.  You need to know that you’re overdrawn and once you’ve clocked that, you don’t need more communications telling you that.’  What you then do with that information – that’s what you need support with.

Rollnick.  Right, so ‘Not hitting the message many times’ is another nice bridge, isn’t it?

Hopkins.  Because I’ve been teaching permaculture for the last six or seven years and I use a lot of things that came out of an approach from Australia called ‘Teaching Permaculture Creatively’, which uses lots of things from different creative teaching fields and a lot of that is to do with this thing of rather than teaching people something, you get them to show other people how to do it.  That actually if someone tells you something, you remember 20% of it, but if they go out and show somebody else practically how to do something, they remember 90% of it.

One of the things I’m planning to do in Totnes is run an evening class – it’ll be a ten week evening class called ‘Skilling up for power down’, and in the penultimate week I’m going to get the people to each write their own twelve steps to breaking their own oil dependency.  So they’ll work out their own twelve steps that will be personal to them, their life, and then they’ll come in the last session and they’ll read out their twelve steps of how they’re going to break that dependency.  The evening class will run on a continual loop because lots of people want to do it.

When it starts again in January, the group who’ve done the first evening class will then hopefully undertake to help the next class out. They will commit to supporting each other in doing that, so that then when a second evening class gets to that stage of the 9^th week, then all those people will come back in and talk about what they did with theirs.  So they’ll be passing that down to the next lot and saying, ‘This is where we got to’.  So you have that supporting cycle, which could be really interesting I think.

Johnstone.  One of the things that can really help is being in a context of engagement and optimism, when you see other people are taking these things on and doing things, but also in a way that involves manageable steps.  That’s also what happens in the centre where I work – we have lots of groups, people coming in with alcohol problems, and they see other people making headway.  We have a client coffee room and garden area where they can spend time chatting.  When you see other people making headway with something, this gives you the idea that you can too.  It becomes something where you have a social context that supports the movement of change, which is different from what many people would otherwise experience.

It’s this thing about manageable steps, plotting out pathways of change, that is also important.  But I suppose there’s this need to think of two sides of change; one is developing and strengthening the will, and the other is finding and having confidence in the way.  And I think with a lot of the environmental issues these two are influencing each other, because if people have the belief that we can’t change the world, these issues are too big – this is the interpretation side really – then what happens is when they get more information about the problem, because they can’t see the way, it just becomes more and more overwhelming.

Rollnick.  That’s right.  So it’s not just a matter of coming to believe it’s worthwhile changing the world that’s important, but also, as your story illustrates, enhancing a sense of can-do.

Johnstone.  Which you’ve written about is in terms of readiness for change being based on both how important the issue is, but also how confident they feel that they can tackle it.

Rollnick.  We could talk a wee bit about those concepts and readiness to change.

Hopkins.  Yes, that would be very useful.

Rollnick.  But we’re talking about information exchange, and I think we’re sort of assuming that there’s a lot of people who feel ambivalent – that’s an insight we can take over to your world, that people feel two ways about it.  And I think Chris has described the nub of that very eloquently and how we can be helpful or less so when someone feels that.  So peoples’ resistance to change has at least two origins; one inside them – that’s their ambivalence, it’s not got to do with the way you’re speaking to them, they feel that inside them; and then there’s the way they’re dealt with.

So there’s an inter-personal cause of resistance if you like, and there’s an intra-personal origin.  And so one way this discussion could go is looking at how do you help people that feel ambivalent?  We talked about the inter-personal quite clearly didn’t we?  I think we’ve just about cracked the principles of poor and better practice when it comes to information giving in health promotion.  Just basic principles here…

Johnstone.  What I find so helpful is this distinction between information dumping and information exchange.  Information dumping is just a one-way flow and it’s all about broadcast.  Information exchange combines broadcast with reception. When you’re broadcasting, you are giving feedback, as in the Frames Model. This involves raising awareness. You throw something out but you also then see how it lands.  It is like saying, ‘Well how does that sound to you?’

You’re then looking at what the information means, what the interpretation is, as well as how they’re running with it.  If you can see that this person is struggling with that, then that’s not the time to give more information.  It’s to look out for times when information is getting stuck in their throat, when they’re finding that difficult. That’s when they need some support in processing that information in a way where it can be digested and they can work with it.

What the distinction between information dumping and information exchange might mean for us is having some principles we could put out in a tentative way, but also inviting a response. For example ‘Well here’s some things we’ve come up with – what do you think?’  And one of them will be: if you have an evening talk or film where you’re giving a lot of disturbing information about what’s happening in our world, that you include in the programme some time for eliciting interpretation from people.  Like, okay you’ve just seen this film – what does it mean?  We don’t just close the evening and say goodbye at the end in a way that people are left feeling stunned or shocked.

Rollnick. The healthcare equivalent is of group meetings of people who’ve had heart attacks – this is my little world that I work in, right?  They have these group meetings in cardiac rehabilitation settings and then use this kind of crude approach, but they give lectures, and people shut down, and people go off, and there’s no digestion time…It’s quite widespread, this idea that people will change if an expert tells them how bad things will be if they don’t.

Johnstone.  There is some evidence that advice information say in giving up smoking from GPs and primary care nurses, does have a limited impact, it’s not completely ineffective.  But also, it’s not going to work with everybody, and like any intervention it can go wrong and can have side effects.

Rollnick.  I’ve been thinking about this.  We could talk about that – if you give someone advice, brief information, why is it that some people change?  We could talk about that because I’ve been pondering that, and I’ve sort of resolved it –why it’s taken ten or fifteen years to resolve it I don’t understand – but anyway that’s what happened.

Johnstone.  I’d really be interested in your resolution.

Rollnick.  Well, I spent a lot of time knocking advice giving, and saying hang on, that’s not an effective way of encouraging people to change – here’s a better way, MI.  And yet we know that sometimes people just get a little bit of information and they change, and there’s evidence for it as Chris said, you know?  So this new book that I’ve been writing with Bill distinguishes between guiding, directing and following, or directing, guiding and following as communication styles. Very simple and…it’s resolved for me because there’s no implication of one style is better than another, which was the mistake I’ve been making – you know like the directing style with brief advice is less effective. Each style has it’s place.

It depends on the circumstances and the context.  With behaviour change, the guiding style’s probably the better default for the reasons that Chris has so carefully articulated – encourage, guide.  If you’re going to have a default style for behaviour change, it’s probably the better one.  But directing and advice giving can work well if it’s personally relevant, well timed and you care – that’s resolution right?  I’m sure that might be one of the explanations why brief advice works.  But it will work better if it’s personally relevant, well timed and done with caring – those three qualities.  You can imagine a GP giving advice to smokers has those three qualities, and the smoker comes out feeling contained, cared about, you know what I mean?  It hit the mark because it was well timed…it was relevant to me, it was personally relevant.  So that’s how I’ve resolved it.  So in this new book I’m paying quite a lot of attention to clarifying what good directing, skilful directing might look like.

The doctor with the good bedside manner probably had the capacity to shift between these styles appropriately, flexibly and humanely, and when it was time to give advice, gave advice.  But also was able to follow and listen, and also was able to guide.  So I think the idea of a good bedside manner has been written off as ‘Oh, that’s just somebody who’s nice to their patients’, when actually I think there’s probably quite a lot of skilfulness packaged up there.

Johnstone.  Again, in terms of crossing the bridge to environmental issues – there are times when it’s really useful to give clear tips on how to address issues, but it’s also looking for that…where you give tips.  This ties back to what you were talking about right at the very beginning about not responding the same way to everyone, moving away from a one size fits all mentality.  And you mentioned that one thing that would be worth looking at is the danger of over-simplifying the stages of change.  Did I get that right?

Rollnick.  Yuh, because I think it’s been over-simplified. There could be a dose-type way of thinking about it – in that stage you do that, in that stage you do that, in that stage you do that. I just don’t think life is as simple as that.  Typically it’s pre-contemplation: give them information, consciousness raising.  Contemplation: they’re ambivalent, give them MI and if they’re in preparation, give them advice about what to do.  It’s got some intuitive appeal but it doesn’t hang together clinically for me, because you can find people who are in contemplation for very different reasons.  If you think about what you call the will and the way, or why-change and how-change – think about that distinction.  The assumption here with the stages of change is that people in pre-contemplation need help with the will, with why-change, that they need all this information.

People at the other end need help with the how, with the way to change.  And these poor fuckers in the middle, I don’t know, what do they need?  They need MI, right.  What is it that they need?  They still need help with the why, which is weigh up the pros and cons, that kind of idea.  But actually if you take 20 smokers in the contemplation stage and you interview them, you don’t come out with it as clearly as that.  You find smokers who are very unready to change who don’t need persuading about the why – it’s the how that they’re hassling with.  They’re in pre-contemplation and they’re in shut-down.  But it’s not because they lack information, or they need their consciousness raised by some wonderful new insight.  They’re in pre-contemplation but they’re in shut-down – they don’t know what the hell to do about it.  D’you see what I’m saying?

Johnstone.  And presumably people can be in different stages with different issues. You could have a drinker who is in the pre-contemplation stage with his drinking and preparation stage with his smoking and contemplation stage with his relationship with his wife – presumably you can be on different ones.

Rollnick.  Spot on.

Johnstone. I find what you’ve just said very helpful – just moving out of the assumption that it’s the why people need when they’re in pre-contemplation, because I see that too.  Sometimes people know about the issue, but as soon as they look at it, so much fear comes up that they think ‘My god, I can’t handle that’. What’s lacking here is the capacity to respond meaningfully to the information.  And if you can’t respond meaningfully to it, people may think, ‘What’s the point of worrying about something you can’t do anything about?  If you can’t do anything about it, then switch it off.’

Rollnick.  With that in mind I’ve had folk from different parts of the world who work in deprived environments come to me and say, ‘You know, people need help with the how!’  And of course, the more deprived people are, the more that is the case.  If you think about the San Bushmen community, they do need help with the ‘how’, big time.  So I don’t see Motivational Interviewing as just residing in the world of the ‘why’ – it’s got as much to do with the ‘why’ as it has to do with the ‘how’.  I don’t believe Chris, when he’s with some drinker and struggling with the ‘how’ will say, ‘Well I’ll tell you what to do mate, why don’t you bah, bah, bah…’  It doesn’t work, people don’t change like that.  So the style of MI and guiding and encouraging people applies across both the ‘why’ and the ‘how’.  And yet I’ve been pigeon holed by the Stages of Change model into apparently defending this idea that MI is for the ambivalent fuckers in the middle and it’s only about the ‘why’.  D’you see what I mean?  And it’s not like that.

Johnstone.  I’m picking two things here – one is Motivational Interviewing as a style, which is about guiding and supporting as opposed to directing.  And that style is something you can apply at any stage of change.  But also there’s the issue of ambivalence, which I feel is likely to always be there anyway, whatever stage of change.  It’s more about the degree to which it’s at the front. I think it’s a useful assumption to have that there’s always likely to be some ambivalence, even if people on the surface appear to be keen, because also motivation is something that can be cultivated and strengthened wherever people are at. If we can give attention to drawing out the ‘why’ then that can strengthen the enthusiasm for change.

Hopkins.  So in terms of this idea of using this questionnaire to assess, to get a snapshot of different communities within a town’s readiness to change, do you see there being value to that – what insights would that elicit and what might one do with them if you did that?

Rollnick.  I don’t think it’s been done before.  So I don’t know. I imagine it’ll be helpful for the very reasons you want to do it, which is you’ll get a photograph of peoples’ different motivational states.  But if we think about the limitations of the Stages of Change model, it’s the implications of action for people in different stages we have to be careful of.  So I suppose we might find it useful to distinguish between the realm of explanation and the realm of action, okay?  This will help you in the realm of explanation in understanding this complex world of where people are at in relation to peak oil.  The implications for action might be something quite different and I can think of lots of examples in my work life and personal life where people will assume that you get fixed on an explanation and action follows immediately from it. CBT’s got that quality.  Your only problem is we need to do a proper assessment. Once we understand your cognitive distortions, the implications for action are quite obvious.

Hopkins.  What’s CBT?

Rollnick.  Cognitive Behaviour Therapy – it’s something that’s in our world.  And when I was trained as a behavioural psychologist, you know…twenty five plus years ago, the only problem I had was to do a proper functional analysis of your behavioural problems.  So to do a proper functional analysis you had to fill out a diary so I could analyse things properly, right?  And then when you didn’t bring the diary back, of course I blame you right?  You’ve got a motivational problem.  But the naïve assumption then was that there’s this realm of explanation, which I’m an expert in and once I know, then the implications for action are obvious. It’s flawed.

So I think with the Stages of Change model, if it helps you understand different motivational things, great, but the implications for action might be something different.  Like you could analyse that San Bushmen community and say, ‘All the buggers are ambivalent and addicted and dependant.  Therefore they all need MI.’ Actually what they’re doing, some smart lawyers have got alongside them and they’ve sued the South African government for taking their land away – the apartheid government before that and before – and they’re getting new land.  And now they own diamond mines right?  And now suddenly they’ve become incredibly wealthy and the whole thing’s going to have to get sorted out.

It happens to the aboriginals as well to some extent.  So the realm of explanation might be they’re a community of addicted, dependent people; the realm of action’s something completely different.  Do you know what I mean?  And in our world we have people with multiple inter-related problems, which is a topic we should return to.  If I come across somebody who’s sexually abused as a kid – this was my standard client in Primary Care that I used to work with. There was a waiting list full of sexually abused as a kid, single parent, history of abuse and physical violence with partner, partner’s buggered off, two or three kids with behavioural problems, agoraphobic, socially isolated and they need a tipple to get out the house.

So now what problem do you focus on there?  Which? They’re all inter-related.  Assumptions about what ‘the problem’ is or what the problems are and therefore what you should do about them…you’ve got to be careful with.  I ended up working in the social sphere – I didn’t become a specialist in sexual abuse because I felt this was the primary underlying problem and therefore the implications for action as sexual abuse counselling…it’s a very tricky one.

But if you get somebody with diabetes with multiple inter-related things it’s a very tricky decision about where should they start?  You don’t necessarily start with the most serious or…you may start with the one that’s easiest but maybe that’s not where they make the most impact.  It’s a very tricky challenge.  And I ended up devising self-help groups for these agoraphobic women so it was a more community response.  So explanation and action aren’t linked. So I think the Stages of Change model would be great for understanding.  I think the understanding might be enhanced by looking at the will and the way, or importance and confidence, or ‘why’ and ‘how’, where their motivational struggles might be, how they feel about how important it is and how confident they are to make some changes in line with something that’s healthier.  Do you see what I’m saying?

Hopkins.  Absolutely.

Rollnick.  So that might be a different questionnaire Rob and maybe that’s something that you take out of it…if you’re doing a thesis you could’ve looked at that, I was just making a suggestion.  But the implications for action I think probably are if the question is good enough you’ll get confused by the data which is a good thing!  It’s compatible with what we find on an individual level – it’s not so simple.  Whereas if you come out with neat, formulaic things like…there’s usually a third, a third and a third – a third will be pretty good and patient, I can make some changes…I don’t know that the implications for action are necessarily…

Johnstone.  What I like about the Stages of Change questionnaire is that it brings a focus on the steps of change that happen before people make the physical change. Often there’s this big focus on have they changed or not, and you’re looking at the end part of the journey when there’s all these steps towards that. If people aren’t making those end changes – like they’re not giving up cars and having solar panels – it’s very easy to feel despondent in the same way that a lot of GPs feel despondent when working with people with alcohol problems. Because even though they’ve been giving all this time they’re still drinking. I think that by applying the stages of change questionnaire a number of times, you can plot movement that happens before the behaviour movement.  So if you think of those levels of change of increase in awareness, change in attitude or motivation, and then change in behaviour, there’s changes that happen before the change in behaviour.

Rollnick.  It is useful.

Hopkins.  Because you come back to it annually in a longitudinal way and assess whether the other things that you’re doing are actually having an effect as well.

Johnstone.  In this whole realm of larger change and addressing ecological issues, it brings the focus to the change before the change, which has often been ignored.  There’s been this idea that if you give people enough information the action will follow, and that’s clearly not the case.

Rollnick.  Yuh.  And I think that’s very useful so don’t take my reservations too seriously because the culture we’re living in, everything is action orientated as Chris is implying, and problem solving.  And the pre-occupation with targets, assessment procedures and healthcare, and deadlines, appointment times, structures, gets people in to the state of mind where it’s all about action and then directing is the obvious style to use.  And I suppose one could build up a critique of health and social care as being all action orientated.  Then with regards to the political spheres, there must probably be similar processes going on.  And understanding change in a slightly more thoughtful manner is a big leap forward.

Johnstone.  As you said, no one has done this before in relation to looking at attitudes about oil use, for example, so just to begin to do it is a step forward. There’s some trial and error whenever you try something new.  It’s like saying, ‘Well this is useful in this field, let’s try it in this field’, and you’ll probably become aware of the problems in the application.  I think what we saying is, ‘These people have thought a lot about difficult behaviour change, and here we have difficult behaviour change, and let’s see if we can transfer some of the insights, understandings and strategies here and see what happens.’

Rollnick.  It’s fantastic, and I’d really like to get right back to the beginning – you used that phrase ‘transfer some of the insights’.  You didn’t use the phrase ‘apply MI as technique across the board’.

***

Stephen Rollnick is Professor of Health Care Communication at Cardiff University and is known internationally for his work developing the motivational interviewing approach. With William Miller, he co-authored the classic text Motivational Interviewing. 

Rob Hopkins is the co-founder of Transition Town Totnes and the Transition Network.  You can read more about him here.

Chris Johnstone is an addictions specialist working in the UK health service and trains healthcare professionals in motivational interviewing. He also runs workshops aiming to cultivate empowered responses to global issues and is author of the self-help book Find Your Power.

Cllr Christopher Wellbelove, Mayor of Brixton, goes Christmas shopping with Brixton Pounds.

Context

The concept of resilience works on a range of levels, not just that of community resilience.  Personal resilience is vital to sustaining both our own and our initiative’s MOMENTUM (3.6) and helping us to deal with POST PETROLEUM STRESS DISORDER (1.1).

The Challenge

In an increasingly isolated and consumer-driven world, we are under constant pressure to value ourselves by what we consume, rather than by the quality of our relationships.  Our lives are busy, stresses are multifold, and look set to increase as the economic impacts of peak oil and the realities of climate change really start to bite.  Without the qualities of personal resilience, or the ability bounce back from shocks to our lives and our expectations, it will prove difficult to support ourselves, never mind our communities, through the coming years of energy descent.

Core Text

In Transition, we look at the question of resilience on a range of levels, from the personal to the community to the national.  What resilience means in the context of our personal lives is one of the lesser explored aspects of resilience.  I asked Dr. Chris Johnstone, author of ‘Find Your Power – a toolkit for resilience and positive change’ for his definition of ‘personal resilience’.  He told me that he sees it as being “our ability to face and deal with adversities in ways that help us get through them or even become strengthened by them”.  Clearly, in the context of peak oil and climate change, and in the work that Transition initiatives are doing, this is a key capacity, both for those trying to catalyse and hold the process, as well as in terms of a quality that the process itself needs to be able to enable.

For Chris, what matters most in terms of resilience are the stories we tell ourselves about it.  If the story we tell ourselves, or our community, is that some people are naturally resilient and other people just aren’t, and probably will never be, or that those who are resilient are the exception to the norm, then this is the wrong story, one that leaves us poorly equipped for times of uncertainty.  If, on the other hand, the story we collectively tell is that resilience is something we all have, which can be damaged or impaired by our life experiences, but which is a learnable, rediscoverable skill, then that is a  story which is far more useful and appropriate.

Child psychologist Ann Masten argues that human personal resilience arises from “the operation of fundamental human adaptive systems that have evolved over the course of biological and cultural evolution”[1], in other words, that resilience is our natural state.  She also argues that there are a number of factors which affect our level of resilience, which, as it were, protect and boost our resilience levels.  Based on a review of many studies on personal resilience, she suggests that these include[2]:

• the strength of our bonds with others
• our experience of affecting change and of personal success
• our levels of intelligence
• our ability to self-control in highly stressful situations
• our feeling that we are part of healthy, functioning social groups
• the degree to which we feel part of the community around us
• larger overarching systems, such as culture, media and religion.

In my discussion with Chris, he described an approach to resilience training that starts by asking people to remember a challenging time in the past that they found a way through. Then he invites them to think back at what helped them do this by looking at four key areas:

Strategies they used, e.g. asking for help, using problem-solving approaches, meditation techniques, attention to diet and exercise etc.

Strengths they drew upon within themselves e.g. courage, foresight, determination, sense of humour, flexibility, ability to communicate etc.

Resources they turned to for nourishment, inspiration, guidance or support e.g. friends, mentors, self-help books, places they felt safe and calm, support groups etc.

Insights in terms of any ideas, perspectives or sayings they found useful. For example, the saying “I can’t, we can”, or the insight that personal and community resilience are powerfully interlinked.

While the letters ‘SSRI’ usually refer to a type of antidepressant, here Chris is using them to map out four key areas (which he refers to as our ‘self-help SSRI’s’) that support personal resilience. All of us will have developed our own ‘toolkit’ of strategies we’ve found useful, strengths we draw upon, resources we’ve discovered and insights that have made a difference to us. Chris suggests the Great Reskilling take these as a starting point, so that we can then learn from each other. There are also specific trainings, such as The Work That Reconnects, the empowerment approach developed by Joanna Macy, that help us cultivate many of the strengths, like foresight, courage and determination, that feed resilience.

It is my sense that Transition is an approach much more designed to enable personal resilience than straightforward campaigning organisations.  Feeling part of a positive and constructive process, working with others, seeing practical manifestations emerging from the work, working with support offered should you feel you need it, with meetings and events designed to ensure that everyone’s voices are heard, these things design the notion of personal resilience into Transition from the outset.  When we talk about resilient communities, it is important that we realise that we are not just talking about windmills and growing cabbages.

In terms of building your own personal resilience, it is, as much as anything, a case of making the time and space in your life to reflect on some of the issues outlined above, and perhaps finding a small group of people that can support each other in this.  The initiative itself can try to keep an awareness of designing meetings, volunteering opportunities and events with this in mind too.

The Solution

Make one of the core activities of your Transition initiative the supporting of increasing the personal resilience of those participating through a range of activities.  Likewise, as an individual engaged in the initiative, try to ensure that you put enough time aside in your own life to focus on your own personal resilience.

Connections to other ingredients

Some of the things that can help to build the personal resilience of those involved in a Transition initiative can include RESPECTFUL COMMUNICATION (1.7), EMOTIONAL SUPPORT/AVOIDING BURNOUT (3.5), PAUSING FOR REFLECTION/”HOW AM I DOING?” (4.12) and regular CELEBRATING (3.4).

[2] Reworded from Masten, A.S, Obradovic, J. (2008) Disaster preparation and recovery: lessons from research on resilience in human development. Ecology and Society 13 (1): 9.  Retrieved from http://www.ecologyandsociety.org/vol13/iss1/art9/ on 25 March 2010.

As part of the evening, each group and project gave a brief report on what they have been doing, which I have since collated into a single document. It was great to get a sense of the breadth and depth of the TTT process, and of all that is happening in its different areas. You can download the Word document here. I hope that you find it useful as an update on the Transition process as it is unfolding here.

The second part was that evening in the Ship Studio at Dartington, with around 50 people coming along to explore the subject of health and sustainability.  Around a quarter of those attending worked in healthcare although, disappointingly, there were no GPs attending, despite their having been invited.  The evening was hosted by Dr. Janet Richardson of the university of Plymouth and of teh TTT Health and Wellbeing group.  The first speaker was Dr. Robin Stott, a GP and Chairman of the UK Medical Peace and Environment Group. His talk looked at the implications of climate change on our approach to healthcare.  Climate change, he argued, is the most significant public health problem of this century.   The other challenge that sits alongside it is that of global inequity and the lack of social equity.  Climate change, initially at least, will affect the poorer people in the world most gravely. 

Our responses need to include informing people and organisations, affirming that we need to both put our own houses in order and advocate for global solutions, and identifying frameworks for global agreement.  The model Stott put forward, which will not be new to regular readers of Transition Culture, is Contraction and Convergence. 

C&C promotes an equitable global agreement, which would reign in the emissions of more affluent nations while also allowing sustainable development of poorer nations.  It transfers money to poorer nations and creates a policy virtuous cycle which enables economic and social progress within environmental limits.  If brought into operation, he argued, it would unleash a boom in low carbon technologies, and would do much to avert the potential public health catastrophe the potential for which is inherent within the climate change crisis.

The second speakers was Lindley Owen, Consultant in Public Health for Cornwall and the Isles of Scilly Primary Care Trust.   His talk looked at action in Cornwall on the climate change issue in the healthcare field.  He began with a quote by the editor of ‘The Lancet’, Richard Horten, “in a global context of energy shortage and inequity, the silence of the medical profession would be criminal”. 

Public health professionals, he argued, now face the challenge of both keeping people healthy and addressing the impacts of climate change, two issues that are increasingly becoming intertwined.  Many of the choices that people should be making for the sake of their own health and the health of their communities are the same choices that benefit the health of the planet. 

In health, he argued, once you prove something, rather than continuing to research it, you are dutyt bound to move on to finding a cure.  Otherwise we would still be researching passive smoking, whereas once it was proved we moved on to tackling it via. public health.  The same is the case with climate change.

Climate change provides a unique opportunity for the public health community to deepen existing partnerships and to create new ones.  He then talked about Groundswell Cornwall, which is acting as a county-wide vehicle for bringing together environmentalists, academics, farmers, academics and health professionals, as well as those from Transition Initiatives across Cornwall.  They have so far produced two excellent reports, one on the impacts of the proposed expansion of Newquay Airport, and the other of the possible impacts of peak oil on Scotland. 

He used the term ‘health co-benefits’, to describe the positive effects of addressing climate change in the healthcare system, greater social cohesion, reduced motor transport, less meat production, local food, better mental health, more active travel, cleaner air, better social networking, a more skilled population. 

So what is the NHS in Cornwall doing?  They have already launched a food programme which is already bringing local and healthier food into Cornwall’s hospitals, they have developed a carbon strategy, they have worked with Sustrans to develop Mobilise!, which is about more active travel, and they have trained a team of Health Trainers, who help people to find non-medical solutions to health problems. 

The third presentation was by Dr. Andy Nicholls of University of Plymouth, and was entitled “Bugs, Birds and Bathing”.  In it, he explored how the onset of climate change could affect the spread of zoonotic diseases (i.e. those spread by animals… there’s your word for the day, and a great one in Scrabble, given that it contains a ‘z’).  One that is attracting a certain amount of media attention is the possible spread of malaria to the UK.  Climate change may indeed lead to localised outbreaks, but he didn’t think it would prove to be a major challenge.

One of the interesting things that came out of his talk was the fact that one of the ways by which malaria is spreading around the world is via. the international trade in used tyres. The small amount of water that sits in the tyres is, apparently, the ideal breeding ground for them.  The UK already has over 30 varieties of mosquito.  Recently, a Cornish village experiences a plague of mosquitoes, leading to lots of press coverage and letters to the local press raising concerns about possible outbreaks of malaria.  Some people did become ill and blamed the mosquitoes, although this is very hard to prove.  Whether mosquitoes will become a real pubic health risk remains to be seen, although there are very real population growth issues with some of them.

The other area is around floods and increased rainfall.  Recent flooding in Boscastle in Cornwall was a good example of this.  Another example was an outbreak of 7 cases of e-coli in Cornwall which lead to children being hospitalised.  On further examination it turned out that they had all played in a stream on a beach, and an intense pulse of rain had washed rain from a field of cattle.  What we are starting to see, he argued, is short, sharp pulses of contamination. 

The final speaker was me, and I tried to weave the peak oil question into the climate change one.  In the same way that cheap oil has come to underpin all aspects of our lives, it has also come to underin all aspects of our healthcare system, from drugs and equipment, to transportation and machinery.  This is not a good plan, as the energy context in which it sits is changing rapidly.  I gave a short crash course in peak oil and how it links with climate change, and then set out the case for our priorities being the cutting of carbon emissions and the building of resilience.  What would a more resilient healthcare system look like?  It would, I argued, reduce oil vulnerability in all areas, seek out less energy intensive approaches, rethink hospitals as farms or as medicinal plant landscapes and apothecaries, prioritise prevention and health promotion, seek to decentralise its services wherever possible and prioritise local sourcing of food and materials. 

I talked about the Transition movement and how it is growing, and then mused on what Transition groups might actually do at the local level to support this, inspired by a presentation given by Pamela Grey at the first Transition Network conference.  They could conduct an audit of all medical resources, both conventional and CAM, identify strengths and gaps, develop healthy living programmes in partnership with others, implement reskilling/retraining projects and develop green herbal medicines as an alternative to pharmaceutical.  I concluded that the medical system can see peak oil as a huge crisis and challenge, or it could embrace its possibilities and potential, which could lead to an extraordinary rethink, which would unleash all kinds of innovative approaches and initiatives. 

A lively discussion then followed, raising lots of issues on all aspects of healthcare.  It is hoped that the evening will reinvigorate the TTT Health and Wellbeing group, and lead to a deeper exploration of these issues. 

Deepest thanks to for their support.

Dr Lindley Owen – Consultant in Public Health, Cornwall & Scilly, with responsibility for sustainability, obesity, PA, nutrition, health promotion, accidents & disability. Involved with transition movement in Cornwall, especially via www.groundswellcornwall.org encouraging new Transition Towns, and developing carbon reduction strategies across partnerships.

Dr Andy Nichols – a Lecturer at the Faculty of Health and Social Work, University of Plymouth who continues to work with and retain links with the Health Protection Agency locally.

Rob Hopkins – Founder of the Transition Town Totnes initiative, director of the Transition Network, publisher of www.TransitionCulture.org and author of ‘The Transition Handbook’, Rob writes and lectures widely on community responses to peak oil and climate change.

Prof Janet Richardson – Professor of Health Service Research in the Faculty of Health and Social Work and Fellow of the Centre for Sustainable Futures, University of Plymouth.

To participate you will go to www.plymouth.ac.uk/health/webcasts where the event will be listed. There will be an ’orange box’ to click on giving you the link (this will only be active on the day of the event). When asked for username please type your firstname lastname as one word (eg johnsmith). (Please do use that format and your own name so that we can know who participated). No password will be required, simply click on the ‘guest’ box.

You will need an Internet connected computer capable of playing sound. Please check this in advance – you may need headphones if your computer does not have speakers.

Your participation will be by typing, i.e. you do not need a microphone. We suggest that you join others in the ‘chat room’ between 1.45pm and 2pm in anticipation of a 2pm start. This will give you a chance to ensure that you are properly connected and have some familiarity with the interface.

If you are joining us for outside the UK you can check your time difference at: http://www.timeanddate.com/worldclock/meeting.html

The paper is called [Food: an analysis of the issues](http://www.cabinetoffice.gov.uk/upload/assets/www.cabinetoffice.gov.uk/strategy/food/food_analysis.pdf) and was issued by the Strategy Unit at the Cabinet Office. It is not a policy document, rather it is the initial findings of a discussion process; the front page carrying the following caveat, *“this discussion paper presents an analysis of a number of the key issues pertaining to food and food policy in the UK. It is not a statement of Government policy”*. It is however a fascinating insight into thinking within Government about food, resilience, and what might be the prompts for a rethinking of food policy.

The report starts by identifying the fact that food culture within the UK is changing, consumers wanting healthier food, but also wanting cheaper food, a tension that has not been satisfactorily resolved. The UK is at the moment about 50% self sufficient in all foods, but between 55 and 70% for indigenous produce. We are also in a context of rising food prices.

In 2002, the most recent year for which there are figures, food related ill-health costs the NHS £6bn, which is 9% of its total budget. At the same time, malnutrition, mostly among the elderly, cost £7.3bn. Obesity is set to rise, and children and young people are most at risk from it. The public health challenge, according to the report, is “urgent and compelling”, and the paper argues that “the diet of the nation and our food culture should be considered in the round”.

One of the intriguing things about the paper is its confusion over the meaning of the term resilience. It almost gets the concept, but doesn’t quite. It uses the following odd sentence when it begins on the subject;

>“Resilience is a more productive focus for food security than self sufficiency”.

You see, as far as this paper goes, self sufficiency and food security are not the same thing. It presents an interesting table (see below) which argues that people are confused about the term food security because it means so many different things. I understand what they mean, but I think it is largely semantic, in the light of peak oil food security means being able to feed your population independent of the input of fossil fuels.

For this report, and it is an interesting insight to see how they define resilience. They argue that resilience is not the same as self sufficiency in food. Rather resilience is about hedging your bets, and spreading the risk associated with where your food comes from. Resilience in food supply can be maximized, they argue, by “a diverse supply base”. As a high income nation with a growing economy we can maximize our resilience they argue by making sure our supplies come from as broad a base as possible.

They do concede that our present ‘just in time’ supply system leaves us more vulnerable, observing that “the very efficiency of supply chains under normal circumstances increases their vulnerability under abnormal ones”. It identifies the challenge of energy security (the standard Government term for peak oil these days), as one would very much hope they would. The building of resilience then, it proposes, comes not from building local, organic food systems, but from rethinking supply networks. The way we farm needs to be rethought, it argues, as existing patterns of food production are not fit for a low carbon, more resource constrained world.

The healthcare system, fresh from appearing to have smoking, for many years the largest cause of preventable deaths, on the run, are looking around for the next battle to fight. Obesity has become that next battle, one that is inextricably linked to diet. The authors observe that 10% of annual mortality in the UK can be avoided with a good diet, and that obesity has trebled in 20 years, with a quarter of adults now officially obese.

I found it all rather intriguing. It suggests that the discussion is at least taking place that climate change means we need to rethink how we feed ourselves, and that that rethink could be far reaching (not an argument that will come as much of a surprise to regular readers of **Transition Culture**). What engaged my imagination is that clearly emerging at the forefront of Government policy is the urgent need to confront obesity in imaginative ways, and that that in turn leads to thinking about how we feed ourselves.

Of course if Richard Heinberg is right, and the UK has to make the same kind of adjustment to peak oil that Cuba had to make, the UK will move from needing half a million farmers to needing 8 million. The move towards more physically demanding work is a good strategy for tackling obesity, but for the Government at this stage to recommend that reintroduction of 8 million new farmers as part of its national food security strategy is probably, in the absence of some kind of mind-focusing catastrophe, not likely to be a vote winner.

So how might Transition Initiatives make use of the insights from this paper? I would suggest that it could be very useful in terms of funding bids. Is a local food scheme just an opportunity to grow food, or is it also a key part of the emerging national agenda on tackling obesity? Might we see a Government, still denying the reality of peak oil (remember the UK government still argues that “on the balance of the available analysis and evidence, the Government’s assessment is that the world’s oil and gas resources are sufficient to sustain economic growth for the foreseeable future”) embracing the uptake and financially backing the rolling out of broadscale urban agriculture on the grounds of lower carbon food production but predominantly as a strategy to tackle obesity?

Perhaps a few hours down at the community market garden could be one of the things a doctor can prescribe for obesity, and perhaps he can also write a prescription to be redeemed against some of the food grown there? It certainly emphasizes the argument for talking to your local healthcare organizations, perhaps a Transition Initiative’s agenda and that of its local Healthcare Trust may be closer than we might think.

**Many thanks to Peter Melchett of the Soil Association for pointing this paper out to me, and for his initial analysis.**

My take is that yes, of course with population levels as they are and consumption as it is, we are too many. Clearly we need to stabilise population, but my sense is that reducing our footprints to one planet which we need to do anyway and which Transition Initiatives are a powerful tool for achieving, makes it possible for us all to co-exist at present population levels. At the recent Food and Farming in Transition event here in Totnes, Vandana Shiva answered this question beautifully. I’ll transcribe it and post it here. Anyway, as the title suggests, this is not a post about population. There is, I would argue, an even greater taboo than population among the peak oil fraternity (and sorority), which is talked about even less, and avoided at all costs. Dentistry.

I remember Sir Bernard Ingham, Margaret Thatcher’s ghastly press secretary, saying something like “I have one word for those environmentalists who would drag us back to the 18th century. Dentistry”. Modern dentistry is very oil dependent, and painless dental work is something we have come to take for granted. In the surgery of the dentist I went to in Ireland he had, as a conversation piece, a dentist’s chair from the 1920s and some old implements. I think it was to impress upon the visitor how lucky they were to be in his comfy padded seat with all his amazing implements.

Ben Brangwyn, co-founder of the Transition Network doesn’t have great teeth, and is fascinated by peak oil, and so therefore has many opportunities to lie with his mouth open pondering the oil dependency of dentistry. Having scoured the internet and found that indeed, dentistry is the final peak oil taboo, with pretty much nothing in print out there, he decided to do some investigating. What follows is his report, which is, I think, a first. At the end he invites your comments, please use the comments box here to discuss any issues around this that you want to.

**Peak Oil and Dentistry.**

by Ben Brangwyn. 21-July-2007.

There is a deafening silence from the world of dentistry on the subject of Peak Oil. As we move into the era that marks the end of cheap and abundant fossil fuels, all healthcare systems will need to adapt to the ensuing constraints, dentistry included.
In this document, two UK dentists respond to a set of questions regarding dentistry and Peak Oil that were recently posted on the ODAC website. Both dentists have chosen to remain anonymous for the moment. They are identified, rather unimaginatively, as Dentist #1 and Dentist #2.

**1. Introduction from Dentist #1**

As a quick intro, here are some notes about the state of dentistry right now. Most of the focus in the UK is on NHS dentistry [as opposed to private], because until recently, this is where the majority of dentists worked. This is now changing however.
Prior to last year, if a dentist had room on his books and a patient called them, that patient would generally be seen (although it was not uncommon to have to wait). However, one has to remember that at that time 50% of the population didn’t have a dentist. The newspapers picked up on this fact and turned it into a big story. All of a sudden, people who weren’t really bothered suddenly got scared because there was a perceived shortage of dentists. This resulted in a flood of people vying for limited places, which resulted in shortages, letters to MPs and more media attention.

In 2000 the government released a document called “Options for Change” which promised to change the way dentistry was done. Under the old system “General Dental Services” (GDS), patients paid a fixed price for each item of treatment, the price being set by central government. In real terms these prices had been below the rate of inflation, meaning that some dentists had to work harder and do more to get paid the same.

Dentists complained and started to go private, so the government set up different trial schemes across the country to try out a new approach. This was known as “Personal Dental Services” (PDS). The dentists loved PDS, as did the patients and the Primary Care Trusts (PCTs), but the government didn’t because, released from financial pressure, dentists started spending more time with patients, doing more prevention, and taking it easier. But this meant that fewer procedures were done for the same money. Gordon Brown (then UK Chancellor of the Exchequer) hated this.

Everything learnt in PDS was scrapped and targets were introduced. At the same time, funding was devolved from central government to local PCTs.

Dentists are now paid to meet targets. Any money patients pay to dentists goes to the PCTs, who haven’t been given enough money by government, and are thus mostly even more in debt. If dentists don’t meet targets they are financially penalised. This is resulting in and ever increasing wave of dentists leaving the NHS.

That’s how dentistry stands at the moment in the UK.

**2. Questions and answers**

**1. Name the top 5 energy intensive procedures in modern dentistry.**

**Dentist #1:** Probably implants, anything involving dental laboratories, and anything requiring a drill. We are moving to single use, disposable everything due to unscientific scares about nvCJD etc. The actual waste produced by dental practices is increasing year on year as regulation upon regulation gets foisted on us.
**Dentist #2:** Agreed

**2. Name the top 5 materials in frequent use that have the longest supply chains**

**Dentist #1:** Cannot answer that, but most dental materials suppliers do offer next day delivery as standard. There was a recent problem with a shortage of local anaesthetic, which is produced in a limited number of plants, all outside the UK. This was due to one company closing down one manufacturing plant and being unable to open its replacement due to USA bureaucrats.
**Dentist #2:** This illustrates the fragility of seemingly secure supplies.

**3. What are the most expensive procedures in dentistry and how might their prices be affected post peak oil?**

**Dentist #1:** Basically implants or anything involving the use of a dental laboratory (dentures, crowns and bridges). With the new contract the government brought out last year, dentists are moving away from the NHS into private practice, reducing the amount of complex NHS work they do in the transition period. This has resulted in many of the low cost / high volume dental laboratories either closing or facing financial difficulties.

We have overseas laboratories trying to break into the cut price market, but they won’t last when peak oil causes shipping costs to rise significantly. UK dentistry is moving more towards a high cost / high quality ethos, resulting in FEWER complex items being made overall. Those without the necessary funds for a private dentist will be forced out of the market and will need to rely on what will eventually become an extraction service (staffed by overseas dentists and graduating or recently graduated dentists). Prices will invariably increase with the increase in overall running costs, as well as increases in the prices of gold, silver, palladium etc.
**Dentist #2:** Agreed

**4. What are the main crucial procedures could we not do without, regardless of the effects of peak oil?**

**Dentist #1:** Extractions, fillings and dentures. Everything else can go out the window. However, dentures are very materials based.
**Dentist #2:** Agreed, though dentures are still very materials based and therefore subject to potential problems in physical supplies and supply chains.

**5. Given the potential disruptions to travel posed by peak oil, how suitable is the current locations of dentist surgeries relative to the people who use them?**

**Dentist #1:** Dental surgeries are different from medical practices in that the vast majority have been set up where the dentist wanted them to be set up. There are many in town centres over shops etc, but it is not uncommon to find them in rural settings, but generally only in connection with high population centres.
**Dentist #2:** Agreed

**6. What is the likelihood of the UK adopting Mobile Dentistry clinics, as per Mobile Dental: Pacific Northwest, USA ?**

**Dentist #1:** There already are a few of these, but with oil at $100, who’s going to pay for the fuel – see comments on PCTs in question 7.

**7. What is the population/dentist ratio in the UK, and is that trending up or down?**

**Dentist #1:** Don’t know the figures, but several studies in the 70/80s suggested that fluoride would mean fewer dentists would be needed, resulting in the closure of several dental schools. This has, today resulted in a shortage of UK dentists, where only half the population now have a dentist that they visit regularly. Money has been pumped into overseas recruitment, and increasing training places, but there is a big problem. The old NHS model resulted in high volumes of work, with dentists each looking after thousands of patients.

The new contract meant that dentists were given targets to meet based on previous activity. Not only is this driving dentists towards the private sector (which means less work being done on fewer people), the recently qualified dentist will emerge into an environment where targets are more important than developing clinical skill. All PCTs will be bothered about is targets being met, and an absence of complaints against the dentist.

The type of dentistry being done will change as dentists feel more and more pressurised (failure to meet targets results in financial penalties for dentists). Many of the overseas dentists are already going back home, fed up with the working conditions. So whilst the number of dentists will increase, the actual level of work done, and the number of patients treated will probably decrease.
**Dentist #2:** Agreed

**8. In the blog New Era Investor – Peak Oil Jobs No.1 – The Dentist it states (towards the end) “Now as I see a trending down in calorific intake mirroring Hubbert’s distribution curve, my advice to anyone assessing their careers is simple. Don’t go into dentistry.” This implies that the requirement for dentists will go down. What predictions, if any, do you have in this regard?**

**Dentist #1:** Well, as I see it, we are in a society near the edges of collapse. I don’t actually think the governmental structures will be able to function in the long run, so spending five years on a dental course may not be in the individual’s best interest, unless a slow steady decline can be envisaged. It all depends on how bad things get.

There may well be a decrease in the availability of refined carbohydrates reducing rates of tooth decay, but conversely, food shortages will of course effect peoples immune systems and will likely increase the risk and rate of gum disease. Also as society trends downwards, people will look for ways to escape from an ever increasing sense of despair through distractions like alcohol and tobacco (a government that wants to cling to power will make sure these are available in my opinion).
**Dentist #2:** I suspect that the requirement for dentists will increase, since it’s likely that health in general will deteriorate, teeth and gums included.

**9. Roscoe Bartlett (Republican Congressman in the US), when asked how peak oil would affect health care in the US, responded with, “Americans have a Ferrari health care system. Post peak oil we will not be able to afford it.” (Peak Oil and the Healthcare Crisis in America ). To what extent might this dramatic assessment be applied to UK dentistry?**

**Dentist #1:** Again, it’s a question of how bad things get. The NHS aspect of dentistry is pretty much doomed. There is a reason the government is hacking off great chunks of the NHS, it costs them £90 billion, which they cannot really afford now that North Sea oil has peaked. The NHS is trapped in a system of increasing expectation by the populace, resulting in ever more complex drugs and treatments, with ever increasing costs, and increasing litigation when things go wrong. This also requires increased specialisation resulting in 5 people doing the job that one person used to do, resulting in more levels of Management and thus more levels of interference, with decreasing efficiency. It’s a vicious circle.
**Dentist #2:** Agreed

**10. How much of dentistry work is handled by hospitals and therefore subject to the additional pressures that mainstream medicine and hospitals may experience?**

**Dentist #1:** Really only braces and surgical extractions, and these departments are usually very efficient because a large proportion of it is done outside of the operating theatre on an outpatient basis.
**Dentist #2:** Also mouth cancer work and specialist reconstructions are handled by hospitals.

**11. What aspects of dentistry would be very resilient in a post peak UK?**

**Dentist #1:** Extractions and simple fillings. Basically emergency “I’m in pain, and I don’t want to be” sort of scenario. All the cosmetic, high end stuff will be limited to practices in locations that can cater to the very rich, places like Wilmslow, London etc.
**Dentist #2:** Agreed

**12. What steps might dentists take right now to wean themselves off their dependence on fossil fuels?**

**Dentist #1:** Not sure
**Dentist #2:** Complex!

*Editor note: It’s not unusual to see this kind of response from any person when faced with the uncertainties of Peak Oil and Climate Change. Ideally, the British Dental Association would be taking a lead here and convening dentists and energy/materials experts to take a proactive stance. This may still happen… “Transition Dentistry” anyone??*

**13. What changes might you suggest for preventative dental care as performed by the public at home?**

**Dentist #1:** Don’t eat refined sugars, at all, period. Do not drink ANY drink that contains sugar. No excuses, do not pass go, do not collect £200. This will not only help your teeth, it will get you off the western diet and a dependency on unnecessary calories. Brush twice a day religiously for at least two minutes. Floss ever day. Don’t smoke, don’t open bottles with your frickin’ teeth and be damned strict with your kids on what they eat. A bad tooth in an environment where there are no dentists can kill you. This is what people seem to forget. Every tooth is an organ of your body and should be respected as such.
**Dentist #2:** No comment

**14. As diets change to take account of much more localised food production, what will be the effect on teeth, and dentistry, generally?**

**Dentist #1:** No comment
**Dentist #2:** The site of food production is unimportant. It’s the kind of food eaten and the basic dental care that is paramount.

**15. Given the potential for economic disruption in a post peak UK, how exposed are dentist practices to, for example, severe interest rate increases?**

**Dentist #1:** That all depends on whether they have bank loans or not.
**Dentist #2:** Agreed, and therefore in reality, I imagine, very exposed.

**16. What is the overarching structure for UK dentistry, and what leadership role might they take in preparing the UK for lower energy dentistry?**

**Dentist #1:** The voice of UK dentists is split between the BDA (British Dental Association) and the DPA (Dental Practitioners Association). Both are absolutely useless and have the leadership qualities of a small moist rock. Dentists are not a united front, and generally can be walked all over by government, which has happened several times over the last 15 years. I can see no hope in dentists even becoming informed about Peak oil, rather than getting ready for it. I do what I can through my website, but I have a limited audience. Peak oil is something that people can easily go into denial about, especially with reporting of the likes of Greg Palast et al who say it is a manufactured rather than a real problem.
**Dentist #2:** Agreed.

**3. The BDA’s view of 2020**

Coincidentally, in 2007 the British Dental Association published their visioning report “Dental Futures – forward to 2020″ .
There’s plenty of business-speak such as, “improving marginal return” and “find ways to maximise their return to remain viable”, and there are some fascinating hallucinations about nanotechnology, such as, “… includes the design and use of small sensors… may provide exciting opportunities in the mouth where it may be possible for teeth to sense changes such as load, temperature… fed back to the dentist to help prevent damage to the teeth”.
However, if you’re looking for an enlightened understanding of energy constraints, you’ll be disappointed. There’s simply no mention of potential disruptions to supplies of materials or energy. The following words do not feature at all in that document:
• energy
• oil
• sustainable
• electricity
• gas
• carbon
• Peak Oil (as if…!)

**4. Conclusion.**

Dentistry in the UK and around the world has a long way to go before it can even start a discussion about dental care in a post peak oil world. In the same way that Transition Initiatives have emerged at ground level to examine how communities can rise to the challenge of Peak Oil and Climate Change, I suspect that it’ll be an informal network of enlightened dentists around the world that will start the conversations that lead to an understanding of how such resource constraints will affect this area.
In the end, it may be the shocks to the economy rather than energy constraints that most affect the provision of dental care. If people can’t afford to pay dentists and dentists’ businesses collapse and banks claim their assets for unpaid debts, then the care simply may not be available. A bizarre thought occurs to me – what would the Nationwide Building Society actually do with 5,000 repossessed dentist chairs? Debt “counselling” with electric drills, perhaps…

On that thought, the more doomsterish among you may want to get the book, “Where there is no Dentist” , companion to “Where there is no Doctor”. These books cover self managed healthcare, typically in communities within the non-industrialised world where access to professionally trained dentists and doctors is very restricted.

On a brighter note, by the time the economy is really feeling the strains of ever diminishing oil supplies, your community may already have fully committed to a Transition Initiative and have implemented a local complementary currency so that scarcity of sterling won’t mean scarcity of money. And by relocalising other aspects of life, you may have rebuilt for yourselves a vibrant local economy replete with dentists, a colourful and cohesive community and most importantly, an abundant and varied local food supply. And if you’ve followed our dentists instructions, you may even have a healthy set of gnashers to enjoy it all.

**5. Message to dentists**

If there are any dentists reading this that would like to form a group to figure out the unique mitigations required by this unique set of circumstances, please contact me at: benbrangwyn@transitionnetwork.org. Anonymity guaranteed.

**6. Message to BDA**

The House of Commons has set up an all-Parliamentary committee to study Peak Oil and Gas and William Rees-Mogg is writing about it in the Times . Now would be a good time for you to build it into the heart of your discussions about the future of dentistry.

**References.**

http://www.nwmedicalteams.org/site/PageServer?pagename=what_mobile

http://newerainvestor.blogspot.com/2005/06/peak-oil-jobs-no1-dentist.html

http://energybulletin.net/17778.html

http://www.gregpalast.com. Palast has varied his views on Peak Oil. Originally he considered it a gouging technique by the oil companies. More recently, he has taken the view that it’s real, though contends that some key aspects are shrouded in mystery, particularly Saudi reserves.
www.bda.org/about/docs/BDA_DentalFuturesReport.pdf
www.transitionculture.org and www.transitiontowns.org
www.amazon.co.uk/Where-There-Dentist-Murray-Dickson/dp/0942364058 or available for download free here: http://www.hesperian.org/publications_download_dentist.php
See Transition Town Totnes’ solution to local money http://transitiontowns.org/Totnes/Main/TotnesPound

http://www.appgopo.org.uk/

www.timesonline.co.uk/tol/comment/columnists/william_rees_mogg/article2080497.ece