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Center for Public Health Preparedness

Transcriptions

University at Albany Center for Public Health Preparedness

Communicate Better to Protect Your Community in a Crisis!

Original Satellite Broadcast: 6/24/09

Kris: Good morning and welcome to the University at Albany Center for Public Health Preparedness Grand Round Series. I'm Kris Smith and I’ll be your moderator today.
Before we start, we would like to ask you to please fill out your evaluations online.
Continuing education credits are available after completing a post test. Your feedback is always helpful to the development of our future programs. We encourage you to participate today and we'll take your calls later on in the hour. The toll-free number is 800-452-0662. You may also send your written questions at any time by fax to 518-426-0696 or by e-mail to the address you see on your screen. Our speaker today is Dr. Barbara Reynolds, crisis and emergency risk communication expert at the Centers for Disease Control and Prevention. Dr. Reynolds, thank you for joining us today. I hope you don't mind if I call you Barbara since I have known you for a while.

Barbara: Absolutely, Kris, and thank you. It's a pleasure to be here today.

Kris: We’re going to have a great discussion but before we get into the questions and answers, there is a videotape we would like you to take a look at.

Kris: That certainly sets the stage for our discussion. Some very powerful images there. So I guess we should start by asking what's different about communicating in a crisis. If you're an effective communicator, why do you have to learn to communicate differently in a crisis, Barbara?

Kris: You know, Kris, that's a legitimate question because after all we're professionals and we know our topic areas, so why can't we just go out in a crisis and speak to the public the way we may do at a conference or a presentation or a community meeting of some sort when a crisis hasn't occurred? But the fact is that research has shown that when people are under threat or when their loved ones, even their pets are under threat, that we actually communicate differently, and people will take in information, process it, and act on it differently when they are under this feeling of threat. So emotions start to play in our communication, and we have to adjust our communication to deal with those emotions.

Kris: And I have heard you say that effective communication in a crisis not only gets the message through, but it empowers decision making.

Barbara: Empowering decision making is actually an important component of good crisis and emergency risk communication because it's not enough just to tell people what to do. After all, we're adults. We're a sophisticated society. What we're trying to determine in a crisis situation is this is a credible message, does this recommendation work for me? And we have to support that recommendation with enough information - it doesn't have to be overwhelming, but just enough information that people can understand as the professionals, as the subject matter experts why you're making that recommendation.
We're not making recommendations in a vacuum. The fact is that there are other people out there talking about what's going on in this emergency.
And there may be people out there talking who don't have the public's best interest at heart. If there are conflicting opportunities or recommendations out there, how does the public know which one should I weigh as having more importance? Part of it is through the credibility of your voice, of your organization, but also part of it is supporting your recommendation with enough information that the public can relate to how you made that decision and why it's in their best interests.

Kris: There are a lot of things you can do right and we'll hopefully discuss those, but there are a number of things that can go wrong when you're communicating in an emerging situation. You talk about five that really are guaranteed to make a bad situation worse. Can you elaborate?

Barbara: I can. Actually, I could spend an entire hour just talking about the five common mistakes that we see in crisis communication when there is an emergency with the public. I would say that I don't have necessarily a favorite among them, but I can certainly elaborate on a few of them. One of the problems that we have is what I call mixed messages from multiple experts. I'm not saying incorrect messages. What I'm saying is when we present a new problem that needs to be fixed through an emergency; there is something that has to be done. And the public is looking for help on solving that problem. If multiple experts are saying different things about how to approach that problem, we introduce a level of confusion and uncertainty. It's uncertain enough in a crisis situation, but by having these mixed messages, different messages that may ultimately be achieving the same thing, but the public can't discern that because to them it's a new topic, it's a new situation, that they are going to be confused by that. They are actually going to lose trust in the overall response and all of the different organizations if we can't speak with a consistent voice.
And I'd like to point out that doesn't mean speak with one spokesperson. What it means is speak consistently so that all the people who are talking about this topic, who are involved in the official response are saying the same thing. It's really important to understand that the public will feel if you change the words slightly, one person is talking about a whole number, other people are talking about ranges, but they are you will ultimately be coming to the same conclusion, that that can add to the confusion and perhaps reduce our credibility in that situation. So mixed messages is a real problem. It's one of the things that we have to work on before the crisis occurs. There are going to be a lot of things happening in the crisis that we can't necessarily predict, but if we're going to be making health recommendations to people, it's our responsibility to begin to build consensus recommendations whenever possible. And if it's not possible, then we have to tell the public be prepared for some changes here. We're going to give you the best recommendation based on what we know right now in this situation as it unfolds, as we get more information, we may have to come back to you and change that recommendation in some way. But involve people in the process, treat them like adults, empower their decision making, and ultimately they will be listening to us. They will come back to us for more information. So that's one of the really difficult areas to manage in our crisis communication but it's a big mistake when we don't do it.

Kris: I remember a few years ago we heard a lot about a one-voice response. Now what I'm hearing you say is what we should be looking at is many voices, one message.

Barbara: You said it perfectly, Kris. That's exactly right. It's unreasonable to think that any one person, especially when we talk about a major crisis where you have 24/7 news coverage of the event and things are unfolding all through the night and into the next day and the next day and the next day. If you only had one person who could stand for your organization or for the response overall to speak, we would exhaust that person pretty darn quickly. So it's really important that we have people trained and ready to go who understand how to communicate to people in a crisis situation, have the correct message and are able to deliver it. It's also valuable to know that depending on the population that you're speaking to, it would be nice to match someone that that population can relate to and take the same message.

Kris: A trusted leader. You had on the previous slide one of the operational guaranteed failures is a paternalistic attitude. Can I talk about that in relation to…I think there is a thought out there that people always will panic when something bad happens and I know you believe that to be very false.

Barbara: It's a belief but it's based on research and on experiences from the past. Often times what we characterize in terms of behavior as panic behavior is not actually panic as we know it from the field of psychology. A panic behavior is when you do something counter to your survival. Often times what you're seeing again, because when people are feeling threatened, they may revert to that midbrain - to the primitive part of the brain and fight or flight kicks in. What you're actually seeing is perhaps an extreme, perhaps not, but response to fight or flight. You're going to be getting different behaviors. In some cases you will be saying that's not what I would be doing so they must be panicking when in fact they are not. They are trying to move forward to protect themselves or to flee a situation that they don't want to be a part of. Both of those options may exist in a crisis situation and it's ok if people choose a different path so we shouldn't be judging them in that way either. But if we label all the behavior as panic behavior, we're doing a disservice to ourselves in the way we relate to the public or our community in a crisis situation and we're also perhaps limiting how we can talk to these people because if we tell them don't panic and they are thinking I'm not panicking, I wonder who is panicking? I'm out here trying to get done what I need to do and they are moving. Sometimes our recommendations are created only for the people who are involved in the crisis itself. And so when other people are starting to take those same measures but we didn't mean to be telling you to do this so why are you doing it, we call it a panicked behavior. They are actually just relating to the event that they see unfolding and trying to do protective measures. It's an opportunity for education more than it is an opportunity for managing panic.

Kris: Let’s relate it to the H1N1 outbreak. Obviously, it didn't occur in every state at the same time. Yet if people in a state where it hasn't occurred yet are going out and they’re buying hand sanitizer and perhaps even some facemasks, we might think it is panicked behavior but really it's just preparatory behavior that is really just good common sense.

Barbara: What we have seen and what the surveys have done is about 23% of the population is basically prepare to be prepared. These are people who already have their hand sanitizer. Then there is a big chunk of the population who will only start to prepare once they see the threat as imminent or that they perceive the threat real to them. And at that point, they are going to start taking some of the behaviors -- we had wanted them to do to be prepared for any crisis but they will do it right then. That's why I say it's an education opportunity. We shouldn't forget to talk to the people who may be facing this in the near future or may not, but it's an opportunity for them to prepare. So it's an education opportunity for those people.

Kris: Do you think that sometimes responders have a fear of fear? They take it as a personal mistake if people are afraid. Yet people are going to be afraid, aren't they?

Barbara: I would think so.

Kris: If it's a scary situation.

Barbara: Exactly, a crisis is something outside of the norm. Often times when something like this happens, it's a natural response and probably a protective response to have fear about what's going on, because fear motivates you to do something. And what we need to do is instead of being afraid of people who are feeling fear or feeling guilty or responsible, that we need to make their fear go away, no. What we need to do is manage that fear. We need to make sure that people are able to do what they need to do to protect themselves, so we don't want an extreme situation, but at the same time it's not our job to make the fear go away. We want them to channel that energy in a productive way by giving them the things to do that they may need to do in that situation or in the near future.

Kris: And so looking for I think to foster personal resilience and community hardiness in an emergency response. Can you talk about community hardiness?

Barbara: Yes. And to talk about community hardiness, I have to talk a little bit about personal resilience, but it's the idea that we can bounce back as individuals, as families, as communities, as a nation, depending on the type of crisis that we're in. And we can bounce back if we tap into some of the more noble characteristics in each of us, and all of us have the potential to be resilient or to have a community that's hearty. It's not just a question of what resources do we have available to us, though we know that people with additional resources in a crisis tend to do better on surviving, but it's also the psychological resources that you have. And the research tells us that mental toughness sometimes can be more protective in terms of your survival than physical strength. So that's how important it is to understand how people are relating to that crisis from a psychological perspective and help them manage that crisis in a way that it builds the personal resilience or the community hardiness. And one of the most important ways is to Foster self-efficacy. That means that we don't sweep in and save the day. What we're actually asking is for people to help us save them and their community in that situation. We need them to pitch in. We need them to understand the things that they can do to make this problem more manageable and for us to recover from the problem more quickly.

Kris: So we need to give them things to do.

Barbara: Absolutely. It's one of the key principles of crisis and emergency risk communication, promote action. It does an important thing. It helps us moderate the fear. By giving people things to do, we reduce the stress, we help restore a sense of self-control. That is what builds the resilience or hardiness that we ultimately need.

Kris: A silly question I guess, but is one more important than the other: personal resilience versus community hardiness? I guess what you're going to say is you can't have one without the other.

Barbara: That's exactly what I will say. I can tell you it's not a sum of the parts. So people can be resilient as individuals but it doesn't automatically translate into a hardy community. There are some other factors that have to come into play. They have to be able to work together. They have to have a community identity. It's really important therefore that we do community planning and that the community feels as a whole that they are part of the solving of the problem. We know there are other kinds of social issues that we're dealing with that if we come together as a community, we can often solve a problem that we can't as an individual. But if each of us do something individually, protect ourselves, we might actually be harming the community in some way that we don't recognize. So it's a combination that works, you're absolutely right.

Kris: Barbara, we just saw a slide giving some factors that contributed to community hardiness. Can you give us some ideas of the factors that contribute to personal resilience? You already said mental toughness. What are some of the other ones?

Barbara: A number of them involve a point of view, a psychological perspective on what you're doing. One of the important things, though, that I would like to stress is that having a purpose seems to be very protective in a crisis situation. Often times, you hear when you're talking to people who have survived in a situation where you wonder how could they manage to do it? Someone that comes off from an icy mountain or that digs their way out of a collapsed building. What they tell us is they did it for their family. They had to get through this. They had to survive for the sake of their families. So that can be a very important thing. As I was working on preparing for pandemic influenza, I thought about what does someone do who doesn't have a family? Where do you go? That's where the community becomes important. If there is a strong community identity, that person can say I'm here to help our community to bounce back. I was watching the television program last night and they were talking about a city that had gone through three major crises along the way, over a span of over 100 years, but the city, the community kept bouncing back. They rebuilt. They came together again. And I wish there was some way for every community to see themselves as the people who can bounce back, who can remain a community no matter what.

Kris: Sort of a can-do attitude.

Barbara: Absolutely, like that little engine.

Kris: One thing about emergencies is their emergence. The situation is changing and evolving. It's always uncertain what's happening and what's going to happen next.
That uncertainty leads to anxiety.

Barbara: It does. Uncertainty is probably more of a problem in a crisis situation than even bad news. One of the things that we need to recognize in a crisis is the absolute demand for information. Amanda Ripley who wrote a very interesting book called "Unthinkable" and it's a meta-analysis of disaster and disaster survival – found that -- or stated, which I couldn't agree more with, is that information in a crisis is like food and water. We need information as much as we need those staples of life, food and water. And if we understood that, I think that we would consider the communication aspect of emergency response in a different way. So we have to get water to them, we have to get food to them and we have to get information to them. Because with information, we reduce uncertainty which reduces the stress and anxiety which can be very harmful to a community or
to an individual in a crisis.

Kris: It's a cliché but we have all heard knowledge is power. You need to have the knowledge in order to empower your actions.

Barbara: Right.

Kris: Well, you have said before, and maybe you will go into it a little more fully now about how we process that information in a different part of our brain. What can we learn about how to communicate better given that we're not going to be receiving the information as well as we normal would?

Barbara: Right. I think this is the point I have to say I'm sorry if you're a neurologist or neuroscientist out there, but what the research has shown us is that in a crisis that we're actually using the mid brain to process a lot of the information. That's where emotion and sensing occurs. Where in the normal times we're doing logic language and reasoning in the forebrain. So if we're going to appeal to that mid brain, there are some special things that we need to consider, and that is that we have to reduce the stress of the emotion by appealing to them in an empathetic way which we can talk about. We need to be sure to give people steps of things that they can do in a way that they believe they can carry it out. And of course without question our messages need to be simple enough that they can be taken in when you're under that fog of confusion, the chaos that goes on in the emergency situation. On a good day, we can only take in three to seven new bits of information. That means if we're under the stress of a crisis, we're not going to be able to take in as much information. So we have to take the time to make our messages simple enough, clear enough, concise enough to break through that fog and get to that person's mind. We have to appeal to their emotions, settle their minds, and then give them simple information. And when I talk about that, I am talking about primarily at the initial stage of a crisis where the uncertainty is greatest. Once we go further into it, people are very open to more information. Of course it's always best if we're making it clear, but they can take in more complex information. But if you try to give people too much information that's not relevant to what they need to know in that moment, it's going to get lost. And we're going to get frustrated because we're thinking we just told you all of this. Why are you asking this again? It's because they couldn't take it all in.

Kris: Maybe it's because public health is such a science-based discipline, but the scientists we work with have all this knowledge. They feel certainly the more information the better for them. I think they feel that's the ideal way. Put it out there. People will pick and choose what they need. That's absolutely the wrong way to go is what I hear you saying.

Barbara: I think so. I think we all have to edit ourselves to tell you the truth, because as I started to talk about the topic I'm most interested in, crisis and emergency risk communication, I find I can babble on a little bit more than where people want to be. I have to pull it back and say what are the essentials, what do we have to boil this down to? I have to say that perhaps Twitter will be the force that makes us do it, because if we all start to learn to talk in 140 characters or less, we're going to learn how to boil down our messages. And we have lost that in the proliferation of electronic media and the fact that people don't have to talk in sound bites much anymore because we're on a cable station which will let you go on for a while. We don't know how to do it. We are going to have to do that though in a crisis so we need to practice that in our exercises.

Kris: If we don't edit ourselves, someone else will and maybe they won’t glean the most important information.

Barbara: Yeah, that’s exactly right. We're just opening it up for confusion and misperceptions. Not by perhaps someone who is filtering our information, an editor of some sort or also the individual him or herself. What we know is sometimes people will pick out of a message those things that they can relate to because it reminds them of something they have experienced in the past or they have read in the past. They will drop out those things that are new to them. What if it's the new piece of information that's most important? We need to filter so we can get the most important messages out first.

Kris: This next might sound a little bit counterintuitive, but your advice is in an emergency under promise and over deliver.

Barbara: Yes and I really want to stress that because I think people who are in the kinds of fields and professions that are involved in operational response for an emergency are typically people who want to help. They have sort of a nurturing nature in some way. They want to make the problem go away. What I find is early on in a crisis situation, there are some times sincere promises made that can't be kept, and we have to be very careful of that because people would become frustrated. They will feel betrayed in some way if we don't keep our promises. I don't think we can sometimes grasp how important the words that we use in a crisis situation affect what people are thinking and believing. If I'm holding onto a deadline that you gave me that in 72 hours we'll have the water back on and it's not back on, I'm going to feel like what? Are they incompetent, did they not care, did they lie? I have questions. I’d far rather say ‘We're working to try to get the water on. It could take as long as this. We hope it won't.’ And then you haven't overpromised - in fact, you have sort of under promised. If you beat that deadline, you get credit for doing it. I don't mean to manipulate people in that way but we do need to recognize that the things we say early on in a crisis, we're going to be held to that. We have to ask ourselves is it in our power to do that? Are there some things that could get in the way of that? If it's not entirely in our power to make it happen, then we probably shouldn't be promising it.

Kris: That's really good advice. I think that probably the overpromising stems from what you mentioned earlier, the paternalistic attitude that we may have. We have to solve this problem on our own. We're going to decide and now defend. I call it the “Dad” scenario.

Barbara: That's exactly right. I find sometimes that we forget that we can employ the community in the recovery, and that if we treat them like adults and say we wish we could get this on sooner than a week from now, we're going to work toward that. Here are the steps that we're going to have to take to get to that. So it's not just a question of giving them an extended deadline, but explain why it may take longer and treat people like adults. Bring them into the process. Overall, your community is going to respond much better and the community will defend what you're doing and why you're doing it because they understand that it's going to take some time and why. It's just a level of honesty and openness that sometimes we lack because we do get paternalistic. “Well, they don't need to know this.”

Kris: Treating people like adults gets back to what you said earlier about acknowledging the fear and placing it in context. If you try to make people not be afraid, you're really treating them as children who see a monster in the closet and you try to convince them they are not there but it doesn't happen.

Barbara: We all know if we're parents that it never worked anyway. In fact, with fear, fear is very personal and sometimes fear can be irrational. We as individuals, if we're not afraid of something, we'll possibly perceive someone else's fear as irrational. But just understand it's subjective. It's person by person. We can't always predict the level of fear that people will have, even though it might surprise us at times that people are afraid. Familiarity reduces fear. And so perhaps the reason as a subject matter expert we may not be feeling fear in that situation is because we have expert knowledge. We're more familiar with it. We may have been tackling this problem for years in anticipation of a potential crisis, and so we have adjusted our thinking around that possibility. But for someone to be experiencing for the first time the kind of crisis that would elicit that kind of fear or emotion, it is not enough to say there is no reason to be afraid. They should tap in and say why is it I'm less afraid of this situation? It could be that I know X, Y, Z. So share X, Y, Z with the public. But here is the danger. As a subject matter expert, you should not follow up that putting the fear in context statement with the X, Y, Z by saying so there is no reason to be afraid, because then I will just be afraid and I will be angry at the same time, because you're attacking me. I feel like you are being paternalistic, but I am afraid and I don't want to be made to feel like a child just because I'm afraid.

Kris: You just told me I'm doing something wrong. As a matter of fact, if you're not afraid, are you very wise? Because this is a scary situation, right? What is it that you're missing?

Barbara: Right. I think that that's a more reasonable way to approach it. With a little empathy say I can understand why you may be frightened in this situation. Let me tell you. And then tell them something that might on their own help reduce that fear. Because again, we want to manage the fear. We don't need to make it go away but we do want to manage it, so if somebody is hypersensitive to a situation, we need to accommodate that to some extent.

Kris: You said earlier that because you are so enamored of this subject that you can tend to speak a lot about it. But you distilled it into three messages. Be first, be right, be credible. How can you do that? Isn't that contradictory to be first and also be right? And if you're not, can you be credible?

Barbara: Kris, any good communicator knows that can be a challenge. You're absolutely right to ask the question. Being first means that we have to understand that for us to have a voice in the overall response as part of the organization that we're a part of, that we need to get out there quickly and tell people we're aware of the situation, here is what our role is, and here is what our next step is. That's how you get to be first. I don't mean you have to be first with every piece of information, but be first as in showing people that you're involved and that you care about what's happening to them, that you're acknowledging the situation. Now, being right and being first sounds like there is going to be a natural tension between those, because after all, it takes some time for us to get our facts straight. What we need to do to adjust to the information age that we're a part of that is becoming more and more prolific in terms of the speed and the channels that are out there to get information is that we're going to have to change the way we think about the information we're releasing. There was a time many years ago when it was ok to wait until you answered all of the questions, the who, what, where, when, why, how, and then you presented your story, your article, your message, whatever it was. Well, today if we know who and what, get it out there. If we are certain of those facts, of who and what, then tell people the who and what. But don't leave it at that. What we need to do is then acknowledge that there are other questions that we haven't answered yet, tell them we're working on it and get back to them when we get the why and where. By building in increments our messages, we're letting people know you're part of this process. We respect your need to know what's happening in your community and here is what we have to give you. Sometimes there is a gap between answering a couple of the questions and the others that are remaining. It's at that point we still again have an education opportunity. So give them a piece of relevant background information that's not specific to the event that will fill in that gap and they will be feeling like they are being fed that information that is as important as food and water.

Kris: Exactly. Let's talk about really quickly the C.D.C. response in H1N1, the communication response, because I saw all of this in action, and, in addition, I saw cautionary statements continuously being made that this information may change. We're learning more every day. I think that's important that you have that caveat in there, that this is what we know now, but it may change and if it does, we're going to let you know as soon as we do.

Barbara: I think that a mistake that we have seen play out in the past is where we go out sometimes sounding very definite about a piece of information that we have, not considering that the chaos of an emergency by its very nature leads to a level of uncertainty that we should acknowledge. So, if we tell people -- it helps us again to first be right in that. We need to be comfortable with the idea that we're going to tell people based on what we know right now this is the best that we can recommend for you, but hold on because we're still out there collecting more information. As we get more, if we think there is a better option for you, then we're going to share that option, too. It was really important to understand that. In the first couple of weeks of the start of the outbreak of H1N1, we were getting some pretty dire information about the severity of this illness. Based on that, we had to make some interim guidance recommendations.
But we also were telling people hold on because we're going to continue to collect information and we may be back to you with different options, and we did play that out.
And I was very pleased with that process for C.D.C. and for other agencies involved in it, because that is truly how you treat someone if you treat them like an adult, not a child. We shouldn't pretend ever that we have all the answers when we don't have all the answers. It's impossible in a crisis situation to know from the moment it starts everything that will be the best way to handle it. You work on it hard and quick. We were doing laboratory work, epidemiological work, a lot of data crunching to try to come to the decisions we did. We're doing the same thing right now. The emergency operations center at C.D.C. is still operating, and we're watching very closely, of course, what's happening here in the United States as this continues, but not only that but we're looking at the southern hemisphere and trying to determine what's happening with this virus in the southern hemisphere in their wintertime, in their cold and flu season. What are we seeing there which will help inform us in terms of what we should be doing for the next flu season.

Kris: To this point, we have really talked about getting information out to the general public. Of course there is the stakeholder audience that we need to think about as well.
Could you define what stakeholders are?

Barbara: It's important to make that distinction because sometimes in our communication planning for a crisis, we're pretty good at getting information out to the general public.
But if you are a stakeholder, you don't believe that just the same information that is given to the general public is enough for you. You're wanting more of it. And a stakeholder is someone who - it's not you deciding who the stakeholder is. The stakeholder decides they are a stakeholder. They believe that you are beholden to them in some way. That they have something extra special at stake, so therefore stakeholder in this situation, and they are expecting special communication to them. Not secret information that you wouldn't give to the public, but that you may need to go a little deeper. You may need to answer specific questions to their needs that the general public wouldn't even have to consider, for example. And so as you do your communication planning for an emergency response, you need to identify based on this disaster that we're planning for who would be stakeholders in that situation. An example out of New York was when we had the introduction of West Nile. We had to understand veterinarians cared about what was happening here. Horse owners cared about what was happening here. People who were running recreation parks cared about what we were doing with that outbreak and our recommendations. We were telling people to cover up and use…

Kris: Bug repellent.

Barbara: Thank you.

Kris: Always according to label instructions, by the way.

Barbara: Yes, yes, yes…but we were pretty specific, but we were also telling people to limit their time outdoors if they were at risk for complications from West Nile. And how would those recommendations affect these different stakeholder groups? It was important to understand it. They may have specific questions for their situation. How do I manage my horses? What do I do to protect them? Do I slather bug repellent all over them? You never know what the questions might be but we have to be prepared to talk to them. That means talking to them through a means other than you talk to the general public. You have to open a channel of communication that works for them. It might be a special website. It might be a conference call. All of those things may need to be considered along the way. But stakeholders are important. Don't consider stakeholders to be our partners and the people we like to work with necessarily. Stakeholders could be someone who is actually adversarial toward your organization. But in this crisis situation, we have to recognize that they need special information and give it to them.

Kris: Because stakeholders often have much a personal investment in the situation, they can sometimes take some special handling, and there is sometimes a tendency to kill the messenger. How do communicators interact best with stakeholders during the stress of an emergency?

Barbara: I think it's important that we evaluate the level of touch, so to speak, which I mean that we have to consider what is the level of conflict and then how do we adjust to it? And speaking of causes of conflict, this slide is showing that this research we have seen that any conflict arises from one or more of these issues, superiority, injustice, distrust, vulnerability, and helplessness. And if you think about that, even in interpersonal relations and all the way up to global relations, you can find these elements playing out in that conflict. And it's a recognition of where the conflict comes from and then adjusting our response in a way that helps to reduce that conflict. Will it make it go away? No. Just like fear, it may not. But we might reduce the anxiety and the emotion and the outrage that could come from that situation. And one of the ways we do that, which is another principle of crisis and emergency risk communication, is show respect. The way you show respect is acknowledging that person's particular special interest in that crisis.

Kris: Distrust you mentioned as one of the causes of conflict, definitely. What can that lead to?

Barbara: Well, if people don't trust you, the fact is that we may have a situation where they also won't listen to you. They won't follow your recommendations. They may ask for things that if they had trusted you they wouldn't have asked for, but coming from you without trust, they are not certain that they shouldn't ask for it.

Kris: But that doesn't happen during the heat of the moment. You have to build that trust beforehand, don't you?

Barbara: It's a good idea if you can. Especially at the community level, you have a real advantage if you're responding to crises within a community that you plan with, because you can build a level of trust, and trust is based on promises fulfilled. That's another reason why we had to be careful about not making promises that we may not necessarily be able to keep. We break trust when we break promises. And it's not necessarily an articulated promise but an expectation that the public has for the way you're going to treat them. So we're talking about ethics and values in the way we approach the response to a crisis. We're talking about respecting people and their place in that crisis, their ability to help themselves and be responsible. All of those components go into our trust building, and that also means making sure that the public, our community has a voice back to us. It's really important because often times we get very interested in pushing information out, which is important, no question about it, but we have to be open and hearing back from people what they need to tell us.

Kris: It needs to be a feedback loop.

Barbara: Sure does.

Kris: It shouldn't just be talking down. Often times, you can really gauge how your messages are being received by just listening to what comes back to you. And it's difficult, especially I would imagine if it's in an adversarial relationship. But you had an idea about actually bringing people who are adversaries closer, making sure that they get the information first so they either feel like they are in the inner circle and like you more, or at least you can get their response in advance and be able to gauge how you will go from there.

Barbara: And we will do that through a number of ways, but at the community level, one of the best ways to do that is to hold a town hall meeting or a community meeting, whatever you want to call that meeting. But hold one of those meetings and allow people to talk directly to you. Now, you and I both know that people tend to go please, no. No town hall meetings.

Kris: It can be a challenge.

Barbara: It sure can be. I think the reason it's a challenge is because we go in there with the wrong expectations. Typically, we say we need to have a town hall meeting so we can tell them X, Y, Z, whatever it is that we want to tell them. That's not why they are at the town hall meeting - because they have an X, Y, Z they want to tell us. So we need to learn to share the time in a different way. Often when we put together a town hall meeting, the response officials, whoever is participating officially in the town hall meeting, will take up half or more of the time allotted for the meeting, doing nothing but talk, talk, talk, talk, talk at the people. While we're talking at them and they are not getting a chance to speak, all they are doing is playing in their mind, well, when I get my chance, I'm going to tell them this or that or whatever, and they are not hearing a thing you're saying anyway, so we're just wasting our breath. I think we should turn it on its head. We shouldn't talk for more than five minutes in that town hall meeting and get the subject matter going and introduce ourselves and then start with we would like to hear from you. Do you have questions? We're looking for questions about this that we can respond to. It's a little messier for us, but once we get comfortable with it, we'll see that we actually achieve more in that kind of meeting situation than if we're just lecturing. And if we allow people to ask the questions, ultimately we'll probably get all the information out to them that we want them to, but they will be listening very carefully because we're responding to their question instead of us choosing to tell them one thing or another. And then I would back it up with making sure I had a handout to give them after the fact that laid out clearly the points that we wanted them to take with them because they might go back and ruminate a little bit about what they had heard and maybe read that and then be more open to it. Because a successful town hall meeting with a group of stakeholders, especially if they are feeling adversarial toward the situation, is that when they leave, they can say yes to this question. Do you believe you were heard? It doesn't mean that we have to take all of their recommendations or do things exactly the way that they said, but they need to know that we heard them. Sometimes that means being able to articulate the point that they wanted to make, whether we agree with it or not.

Kris: Barbara, sometimes it seems that we go into a town hall meeting to hear people's concerns, but we haven't resolved to really address them. It's more that we want to convince them that our way is the best way. And that can really damage your trust, can't it? I mean, is it important to say up front we want to hear what you think and we're going to try to incorporate as many of the recommendations as possible. But we need to let you know we may not be able to do everything that you're asking us to.

Barbara: I think that's fair. Again, you're talking to them like they are an adult. Any kind of a meeting we have where a decision has to be made, you have to weigh the risks and benefits, the costs and benefits of each decision that's made. And as long as they know that you're fairly applying a process to the decision making and that you are taking into consideration or have taken into consideration the point of view that they have, you will do much better. I really think it's a mistake to go into a public engagement situation and know that you have already made up your mind, but you're doing it for window dressing. If you're not going to give them a voice, if you're not going to consider what they have to say, then don't insult them by asking them for it.

Kris: Because they will know.

Barbara: Of course they will.

Kris: They will certainly know when none of the recommendations are taken….don’t recognize in a format they suggested to them. The other thing you said that was I think very, very important, was that they need to know they are going to be heard. Obviously, you don't always have time at a town hall. I have heard a recommendation that I think might be viable. Have people write down their questions on index cards or somehow have an Email address, but make sure you get back to every question with an answer.

Barbara: I think that's excellent. That's actually a technique we use internally at C.D.C. when having a meeting with the work force. Obviously, when you have thousands of people working with you and they may all have questions, you can't answer them at one sitting, but we offer - first we allow people to submit questions early in writing, which is helpful. Then we'll answer representative questions and make sure that we do hit most of the high-level topics that we can, and then we go back, get the answers for others and post them on a website, intranet site so that the people can go back and see them. And why not apply that same thing to our community? After all, if we're treating them respectfully, we know that what they are asking us is important. What's really vital, which I have learned over time, is sometimes the questions that the public asks us early on, especially the ones who are more upset, they are telling us where the situation is going. That can tip us off to trends and things that we need to be prepared to answer along the way, when we may not have considered the question. So it's nice to get those questions because they might seem a little off the proven track, but sometimes they become the issue of the day, so to speak. So hearing back from people and getting their questions and their concerns will make us better communicators in the crisis.

Kris: It's a way to gauge the temperature of the moment and what's happening in the future.

Barbara: Right.

Kris: We do w want to give everybody a chance to call in with questions for Dr. Reynolds. We're ready to take your calls right now so we hope you will pick up the phone. The toll-free number is 800-452-0662. You can also, of course, send your written questions by fax. That number is 518-426-0696. Or if you want, e-mail them to the address that you see on your screen. While we wait for calls, and certainly hoping we will have some because Barbara is certainly just a wealth of information on this topic - can you distill what you have told us to maybe six principles?

Barbara: I certainly will try. Will I remember it? Yeah. There are six principles that are further foundational to the crisis and risk emergency communication. In that framework, what we're trying to do is show respect and understand the psychological stressors that are occurring in a population in a crisis situation. And the first three we talked about quite a bit which was be first, be right, and be credible. And being credible means being trustworthy. It means being honest and open. And the first, being right, make sure we can release information in increments to people. The other three we didn't talk about quite so much which is expressing empathy. That is a word that if anybody has been through my training they know I really stress, but it's important to understand that when people are processing information in the mid brain where there is emotion and sensing primarily going on and less logic, language, and reasoning, that by expressing empathy, it means putting into words the emotions that people are feeling. So you can't say I know how you feel. You have to say I understand this is frightening. Or this could be an anxious time for all of us as we wait to hear the answer to this question. So, just acknowledging in words what the people you're talking to are actually feeling goes a long ways in reducing the stress that they are feeling, that anxiety, and then they can hear your message. Because again as we talked about, if people are under too much stress and their emotions are too high, they can't hear the message. By acknowledging that emotion literally helps to calm it down. And then promoting action, which we talked about. Important to give people things to do that they actually can carry out and overarching on that is show respect. Treat people the way we want to be treated, the way we want our loved ones to be treated, and we'll do the right thing if we continue to think in that way.

Kris: We do have a couple of questions but I wanted to touch on that promoting action. You believe it's important not only to suggest the action, but explain why, why it's important.

Barbara: Yeah.

Kris: So often that doesn't happen. Just take our advice. Just do this. You will be ok.

Barbara: Amanda Ripley in her book "Unthinkable" stresses this in a way I can't help but use. That is if we're on an airplane and the flight attendant gives a safety briefing and says if there is a loss of cabin pressure, then put on your mask and help someone else. I have always thought gosh, that's not very polite. I should help the person first. I would be selfish to help myself and then help someone else. Well, as it turns out, if you understood why they were making that recommendation, it's because it's not like holding your
breath underwater. If there is a loss of cabin pressure, you will lose consciousness very quickly. The only way you can help that person is to first help yourself. Otherwise, you will be putting a mask on a person who can't help you and then you're in trouble.

Kris: Nobody tells us why.

Barbara: No. If I had known that -- I had just discounted that recommendation, thinking no, I would help my child first before I would help myself. That's our nature to do that. No, we have to help ourselves in order to help someone else. Now I know why, I can do it.

Kris: That actually segues into one of the questions that we have received which is about the advice from FEMA, C.D.C., many government agencies to be personally prepared. At least a 48-hour supply of food and water, etc. So often people aren't told why do we need this? For instance for a pandemic. Why do I need water if there is a pandemic? I think we need to say because maybe the essential services that we have been used to won't be there. Or maybe you will just need to stay home at a time when the virus is most pronounced in your community.

Barbara: Right, right. And if we're not doing a good job of explaining why, then we need to do more. Because it is important to understand. We talk about preparedness, for those people who are willing to prepare absent the threat, as an all-hazard preparedness. You can pick and choose your crises and say I might not need it for this one, but there is no guarantee that one crisis won't overlap another. You really don't know. It is not a bad idea to have some of the essentials of life ready for you in whatever event may take place.

Kris: It could be a blackout during a pandemic. If the utility company workers are sick and can't get to you for much longer than possible.

Barbara: That's right. We're actually fortunate in a weird sort of way. If we have experienced a minor disruption of services in a way, that we would have to walk through the what if. What if this happened, what would I do? That's really what people need to do. Or think it through. It's hard sometimes to do it when you're feeling comfortable, but it's worthwhile. I mean, even if the water in your tap isn't safe to drink for some reason, what are you going to do? What is your plan B? It would be nice if we prepared for it.

Kris: I wish we could talk about this all day but we are running out of time. Before we conclude, there are some guiding principles that C.D.C. uses in terms of their communication that I really hope you would share with our viewers.

Barbara: Thank you. Just understand that these are guiding principles that have been in place at C.D.C. for numbers of years. We aspire to them. But if we do these things, we're incorporating some of the concepts of C.E.R.C. along the way. That means we have to work it being as open and as honest as possible. If we're going to tell our loved ones this information, why can't everybody's loved ones have the information? That we don't try to spin and we're not looking to manipulate people and that is a component of crisis and emergency risk communications to make sure that we're treating people with respect and not trying to manipulate them psychologically, but to acknowledge what's happening to them. And then that if we do something, if we make a decision, we're responsible as an organization for that decision, and we have to explain how we got to where we did, and if necessary apologize if we did the wrong thing along the way. That's an accountability factor. Accountability actually adds to trust.

Kris: It keeps your reputation intact. Your reputation needs to be intact for you to be credible.

Barbara: Absolutely. People have the right to discount us if we are not a trustworthy source for them. We have to work very hard. As a government organization, we have to work even harder. All of us in government do to include that credibility.

Kris: Thank you so much for this discussion. It has just been terrific. I encourage everybody to get your training if they can. It's just, it's invaluable. We want to thank everybody for joining us today. We would like to ask that you please fill out your online evaluation. Your feedback is very helpful in planning future programs and continuing education credits are available after you complete that post test. This program will be available online within a week or so. Please check our website for details. I'm Kris Smith. Hope to see you next time on the University at Albany Center for Public Health Preparedness Grand Round Series. Thank you so much, Barbara.

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