Narrative Change and the Open Society Public Health Program

The phrase 'narrative change' has in recent years peppered the conversations at, and shaped the work of, the Open Society Public Health Program (PHP). In order to prevent this term from becoming trendy yet imprecise as it enters the lexicon of several organisations, this paper defines the concepts 'narrative' and 'narrative change' and explains why they are important. The Open Society Foundations (OSF)'s Brett Davidson: examines narrative change and its link to attitudes and values; looks at the role of narrative in policy change processes, narrative change at the level of culture, and the ways in which policy and culture interact; outlines some of the narrative change methods being used within the PHP; and discusses several questions related to risks and ethics.

Narrative consists of a collection or body stories of characters, joined in some common problem as fixers (heroes), causes (villains), or the harmed (victims) in a temporal trajectory (plot) leading towards resolution within a particular setting or context. These stories together or collectively convey a common worldview or meaning - an interpretation of the world and how it works. Narratives are reflected within cultural products, such as language and other forms of representation. Operating at an emotional as well as cognitive level, narratives cannot be evaluated or challenged empirically but, rather, according to whether they are coherent ("narrative probability") and whether they "ring true" ("narrative fidelity").

Here, everyday people have a role to play in what communication scholar Walter Fisher calls a "public moral argument" - argument over questions that involve competing values and deal with questions about life and death, how persons should be defined and treated, and so on. Davidson explains, "Under the rational paradigm, such questions are reduced to technical ones to be decided by experts, and the public are reduced to mere spectators. However, under the narrative paradigm, experts may provide knowledge and counsel but the public must weigh the competing 'stories" and decide. The narrative paradigm gives legitimacy to concerns that are normally dismissed by technical experts - factors such as trust or distrust of decision-makers, fear or hope, individuals' self-conception, values, and their pre-existing stories of how the world works."

At the individual level, narrative change focuses on influencing individuals' attitudes/opinions in order in turn to influence public opinion more broadly. For instance, by changing the stories told about (or changing the symbolic representation of) a group of people, we hope to change beliefs about those people and thus to alter attitudes. Many times we would also hope to change behaviour (such as discriminatory treatment in hospitals). When individuals hold conflicting attitudes, beliefs, and values, the goal may not be to change them but, rather, to activate or change the salience of particular existing beliefs, attitudes, or values relative to others. Narrative change techniques often do this through "framing" - e.g., messaging to advance a policy restricting the pricing options of pharmaceutical companies may seek to use a narrative that activates the "fairness" value in the audience, while downplaying questions of "freedom". In some cases, the aim is not to change attitudes so much as to alter their strength or intensity by creating a sense of urgency, or by simply showing people that the alternatives they already favour are indeed possible.

If narratives are powerful, socially constructed mental models that shape our perception and understanding of reality and thus guide individuals' decision-making and behaviour, it makes sense that narratives play an important role in policy processes as well. In this context, "narrative change" comes into play, Davidson asserts, when we explicitly adopt a change strategy that sees narrative as a core element. Policy change theories recognising the importance of narrative strategies include the Advocacy Coalition Framework, the Punctuated Equilibrium Theory, and the Narrative Policy Framework (NPF). The NPF posits 3 levels in which narratives play a role: the micro level of the individual and how individuals inform and are informed by narratives; the meso level, in which groups and advocacy coalitions deploy narratives within the policy subsystem; and the macro level, in which narratives are embedded in cultures and institutions and shape public policy.

Looking more closely at the latter level, Davidson observes that culture can interact with policy in complex ways. Considering that "Cultural narratives are intimately tied up with questions of power", "any organization concerned with human rights, with questions of power and inequality, needs to pay attention to narrative and the way in which it operates. While coercive power of course operates in many ways, through laws and institutions and other physical forms, it is not sufficient to challenge institutions and other manifestations of coercive power if we do not also work to destabilize the control mythologies that provide them with a cloak of legitimacy." Davidson examines the work of Peter Hall (1993) as a means of clarifying the interaction of cultural and policy change. Hall argues that there are 3 orders of policy change, and the third level entails a paradigm shift in which targets, instruments, and the very hierarchy of goals all change simultaneously. Here, "Questions of authority become crucial - there is a shift in who is regarded as authoritative on policy matters. The role of technocrats becomes secondary - politicians, civil society and the media all exert influence." Davidson observes that Hall's depiction of third order changes looks very much like the competition of alternative narratives that Fisher talks about (public moral argument and "preferred patterns of living").

Turning from definitional and theoretical issues to the more practical and applied, Davidson outlines some of the major ways in which the Open Society PHP works on narrative change. In brief, the strategies include:

• Arts and cultural or artistic activism, which makes use of what Stephen Duncombe and Steve Lambert of the Center for Artistic Activism refer to as "symbols and signs, images and expressions" in order to have an impact. There are many examples of such activism, such as "legislative theatre" staged by Theatre of the Oppressed groups in various places around the world. If such activism is to be not only creative or artistic but also effective, any sort of intervention has to begin with a strategic analysis. Davidson presents a series of questions to help stimulate such an analysis. Based on the analysis, action entails the undertaking of specific public actions that challenge dominant stories and offer alternatives. Evaluation and adaptation tend to happen through qualitative reflection, analysis, and discussion amongst the activists themselves, rather than through formal testing. The PHP has applied the approaches outlined above in a range of contexts. For example, in late 2015, the PHP supported the Center for Story-Based Strategy to facilitate a narrative power analysis exercise with a coalition of activists working to transform the medical innovation model in Europe.
• Popular culture: television, film, social media, comedy, music. For example, in April 2016, the PHP was involved in an OSF-wide collaboration to support civil society mobilisation demanding reforms to international drug policy during the United Nations General Assembly Special Session on Drugs (UNGASS) meeting. This included funding for a pop-up Museum of Drug Policy, which was open during the 3 days of the UN meeting and included art works, photography, installations, and cultural programming. Davidson also discusses narrative medicine, which is particularly relevant in the context of the PHP's work on deinstitutionalisation and mental health, and the way in which patients from criminalised or marginalised groups, such as drug users and HIV-positive women, are treated within healthcare settings.
• The realm of metaphor and cognitive linguistics, which is more systematic and research-based and involves 3 stages: (i) an analysis of existing messaging and language used by the various parties in a particular narrative context - e.g., a content analysis of news coverage of a particular issue over a defined time period; (ii) research into the intended audience to better understand the narratives active in their understanding of the world and of the particular issue at hand; and (iii) development and testing of messages based on insights gained from the previous research - e.g., through use of focus group discussions. A limitation of this approach is that it can be expensive because of the extensive research involved.

Along the lines of the caveat just mentioned, Davidson concedes that, although he considers narrative change to be an important area of work, it is difficult to do and often a long-term undertaking. Some challenges include:

• It is difficult to determine impact.
• It is difficult to define success.
• There is no clear body of knowledge on narrative change.
• Narrative change work is contextually and culturally specific.
• It is work that takes place in contested terrain.
• Narrative change is manipulative and thus in some sense unethical. Davidson writes, "It is important to bear in mind that purely rational and evidence-based communication has its own limitations and is also subject to the cognitive biases that are inherent in any human endeavor....[A] turn to narrative is about adopting a particular paradigm of communication that works according to specific rules. By operating in a mode of discourse that people in fact use to engage in moral argument every day, narrative techniques can make complex debates accessible to the most diverse parts of society, to non-experts and thus have potential to open the space for increased participation rather than confine discussion to technocrats well versed in policy issues." In short, he argues, it is possible to engage in narrative change in an ethical manner by seeking to make assumptions and intentions visible, rather than to hide them. "Where possible we should seek to open and expand the window of options and alternatives rather than restrict them."

In conclusion: "We will no doubt face many setbacks and dead ends. But it is work that, if successful, has potentially huge impact in transforming the social and cultural context within which much of our other advocacy work takes place."

Click here for the 22-page paper in Word format.