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Positive Deviance

Posted By Deepu George, Tuesday, May 29, 2012

Members of the audience stood up in unison to applaud the plenary session given by Dr. Arvind Singhal, a distinguished professor of communication at the University of Texas, El Paso, Texas. He was speaking to all of us at the American Family Therapy Academy (AFTA) annual conference in 2012. With compelling stories to each of his points and almost theatrically perfect oratory skills, Dr. Singhal provoked family therapists to think deeply about social complexity and how contexts often generate positive deviance and generative relationships.

Positive deviance is an approach that enables communities to harness, spread, and leverage existing wisdom to amplify apt solutions. In other words, Positive deviance exemplifies deviant behavior that leads to better, sustainable results to a particular problem. The so-called innovator of this solution manages to create this solution at no extra cost or access to additional resources. Additionally, these solutions are culturally relevant and easily transferrable from one person to the other. Positive Deviance therefore is often behaviors that are not expected from individuals but the performance of such behaviors has a positive influence on the whole system. Singhal and colleagues have been applying positive deviance to a number of health care scenarios, nutrition related issues, and other issues that are embedded in the social narrative.

Positive deviance then occurs within contexts of social complexity. Social complexity consists of roles, privileges, authorities, hierarchies, inequalities, and the various oppressive discourses of our times. It is in this context that a few individuals are able to become deviant in a positive way that dramatically influences certain outcomes. Dr. Singhal recounted two experiences that offer examples of positive deviance that are useful to family therapists in medical settings.
Deepu George
The information contained in simple deviant acts is the "difference that makes a difference".

Incident one was about a pediatric anesthesiologist who treated his son, who due to complications had to remain in the NICU for about the first 2 years of his life. With repeated intrusions by needles and instruments to the baby’s body, he would often tense up and cry when something sharp, cold, or metallic would touch his body. However, things were different when Dr. Virginia Mohl, the pediatric anesthesiologist came in the room before the boy went in for surgery. She would immediately pick up the child, soothe the baby by speaking to the baby, gently caress him while humming and speaking to him. While she engaged the child and as he responded to her warm touch and care, the necessary injections and procedures would be done without the baby bursting into tears and a loud cry. As she would take baby into the operation theater, she would often turn around and tell the parents "Your boy is going to be just fine. I have done this a 1000 times.” Singhal recounted that as parents, they never felt more confident than when Dr. Mohl was in charge.

The second story is about an unassuming doctor in charge of rounds with medical residents. Walt Fairfax, the division chief for hospital medicine would never wear a tie and always was in short sleeves. Dr. Singhal narrated about whenever he came through for rounds with his residents; all of them would have a funny looking folded equipment with them that looked like an umbrella. As soon as they came near Dr. Singhal’s son, they would all open up this umbrella which turned into simple chairs they would sit on. As all of them sat around the baby, they would invite the parents over to their circle for conversation. Their first question was always "Mr. and Mrs. Singhal, how do you think your son is doing?” and then would start a conversation. The parents felt included, respected, and felt confident about the treatment process. All other practitioners who took care of their son all had similar trainings and excellent qualifications. They read the same charts, used the same equipment but did not make a difference to family. Both Dr. Mohl and Dr. Fairfax did make a difference. This apparent aberrant behavior, a behavior that is deviant but made a positive difference is Positive Deviance.

Despite the existing norms of how others in the hospital worked and dealt with patients, both of these doctors were able to bring a different sense of hope and healing to the entire family. It also transformed the particular views of individuals who worked with these two individuals in that hospital. Their relational approach generated a new dynamic between the family and the medical team that was deviant, yet positive. In being deviant from the norm, their behavior improved quality of care with no additional resources or expenses to the overall system.

The positive deviant approach is not much different from what Collaborative Family Healthcare Association is trying to achieve in its overall mission. With the goal to provide "comprehensive and cost-effective model of health care delivery” in working with multi-disciplinary teams, our overall philosophy itself is a deviant from the norm. As the field grows more organized and as rigorous training sets us apart, the question remains how good are we and will we be at detecting positive deviant behavior in our own collaborative teams and environment?

The behavior of positive deviance emanates from everyone, not just experts or people who have been trained. Dr. Singhal speaks of Jasper Palmer, an attending at the Albert Einstein Institute of Medicine whose method or de-robing prevents and contains infections in the hospital setting. With Jasper’s groovy moves, he de-robes himself by squishing his head cap, to gown to gloves and rolls them up in a bundle and gently places it in the dispenser. This method now known as the "Palmer method” reduces contaminations and MRSA, a health care associated infection in hospitals which costs more than $10 billion a year.

Positive deviance is not only an exception in terms of the act of behavior but also has deep and profound connections to the cultural and structural aspects of a system. Building contexts where relationships are generative and collaborative increases the likelihood of positive deviance. In a hospital setting where a MedFT or a nurse feels comfortable enough to tell the chief attending physician that he forgot to wash his hands from a previous appointment is a nurturing context for such deviant behaviors. Settings in which hierarchies and job titles define treatment approach rather than a collaborative setting, positive deviance is not likely to occur.

Gregory Bateson, dedicated learner of the inter-connected nature of human life and the broader ecology spoke of information as "the difference which makes a difference.” The information contained in simple deviant acts is the "difference that makes the difference” for many around them. As medical family therapists and other professionals in the Collaborative Family Healthcare Association continue to make decisive differences to lives of many, let us remember to blaze a deviant (positive) trail in our practice settings that helps us to achieve our mission of delivering comprehensive, cost-effective healthcare to all families and patients we will learn from.


Deepu George is a doctoral student in the Family Therapy program at the University of Georgia. He is interested in social determinants of health, medical family therapy, community development and capacity building. With a Masters Degree in Holistic Psychological Counseling from Bangalore, India, his aim is to continue his passion for applying systems lens in health care, family therapy, community capacity work.

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