The Social Psychology Theoryof Social Proof and the Community Acupuncture Model
By Krista L. Hite
September 28, 2008
Casually listening to NPR one afternoon, an interview with social psychologist and author, Dr. Robert B. Cialdini, on the topic of persuasion unexpectedly caughtmy attention.At first I assumed I’d tune him out, but found myself in rapt attention as he began to describe certain social psychology features most of us share.It caught my attention because what he was describing is exactly what the Community Acupuncture (CA) movement is all about.In particular, he was defining and categorizing the very practices the founders of Working Class Acupuncture (WCA) have implemented at their own clinic and have fostered in the CA movement.The interview quickly diverged from the seemingly superficial topic of persuasion and centered on the fascinating phenomenon termed, Social Proof.
Social Proof defined:when people are uncertain about acourse of action, they tend to look outside themselves and to other people around them to guide their decisions and actions.
Essentially,Social Proof theory describes how we operate as social creatures and how important our peers are to us when making decisions.The phenomenon of social proof in decision making canmanifest in both positive and negative outcomes and the outcome is typically determined by factors such as perception and word choice in a request orproposal.
For example, Cialdini shares a good outcome as demonstrated by an experiment performed in a hotel to reduce the number of towels used by guests in an effortto reduce the hotel’s laundering expenses.
Two signs were used to try to persuade guests to use fewer towels:
1-“Re-use towels to save the environment.”
2-“The majority of our guests re-use a towel at least once during their stay.”
Both messages are trying to persuade the guests to “do theright thing.”The difference though is that #2 introduces a social component in the request.As a result, guests who viewed sign #2 increased the re-use of towels 26% over those quests who viewed sign #1.This reveals that our peers and their choices matter to us and influence us in ourdecision making process.We want to do the same right thing that our peers are doing. This is Social Proof inaction.
On the contrary, negative outcomes are common, from the IRS discouraging rampant tax evasion fraud and consequently increasing fraud to seemingly benign and straight forward pleas to act in apro-social fashion. For example, Cialdini shares a story about the theft of artifacts from a petrified National Forest.In an attempt to preserve the forest, a sign was posted which can be paraphrased as stating,
“Because so many people are stealing petrified crystals and artifacts from the forest,the integrity of the forest is being undermined. Please don’t remove artifacts as souvenirs from the forest.”
Prior to posting the request, it was estimated that only 2%of the visitors were stealing artifacts.Astoundingly, Cialdini reports, the forest experienced a 300% increase in theft after the sign was posted. The wording of the sign suggested that most visitors’ peers were stealing artifacts,so why shouldn’t they? The perceived actions and decisions of their peers gave a signal as to what the correctchoice was despite the request to “do the right thing.”The right thing was evidenced by theperceived actions and choices of their peers.
In sum, how information and requests are presented impact perception and thus ultimate choices.People want tobe a part of a larger group of peoples all doing the same thing.This can have truly good consequences when working towards social justice in health care.Keeping the reality of the phenomena of Social Proof in mind when engaging with patients can help CA clinics grow and be prosperous while increasing access to health care for people who need it.
The theory of Social Proof indicates that when the CA mission is conveyed correctly, it allows people to join a movement working towards personal,community, and global well being.At the same time, CA clinics can grow a dedicated and galvanized patientbase committed to the CA mission of transformation of healthcare delivery inthe US.This translates into aprosperous bottom line as well and justly so. The mission of the CA movement isto provide for sustainability in healthcare as well as a sustainable professionfor acupuncturists.
When considering these social science facts, the success of WCA is demystified.Whether acting as savvy entrepreneursor following their instincts, WCA has implemented facets of Social Proof aswell as other social psychology tenets such as the Rule of Reciprocation andthe theory of Correct and Unifying Choice.And this has been done for a noble purpose.This contrasts sharply with the insidious practices used by the advertising industry which capitalizes onsocial psychology by persuading the public to mortgage their futures via creditto join the crowd in living above one’s means. As the examples above demonstrate,people seem to be wired to be a part of a collective, a community acting insimilar fashion.This social factor has been tapped by WCA in many ways and can be tapped by other CA clinics and practitioners as well.
Let’s look at the other social psychology principles Dr. Cialdini referred to duringhis interview, Rule of Reciprocation and Correct and Unifying Choice and reviewparallels with WCA’s business model.The Rule of Reciprocation in Society, according to Cialdini, summarizes the desire people have to give back to those who have given to them.This is why marketers, corporations,and waiters give gifts to their current or prospective patrons.Cialdini recounts an experiment involving wait staff using complimentary mints when providing the check to their patrons.He noted that waiters who left a mint with the check saw a 3.3% increase in their tips overchecks left without a mint and those who left two complimentary mints saw are markable 14% increase in their tips.Obviously, CA acupuncturists are not working for tips, but the Rule of Reciprocation can and has been applied to varying degrees in CA clinics.
WCA has promoted the use of free treatment, patient appreciation days, as well as arming their acupuncturists and support staff with free treatment cards to handout as they see fit.These practices tap into the Rule of Reciprocation in terms of patient retention,patient referrals, and increased patient numbers.In essence, patients give back to the clinic and their practitioners by returning, motivating their friends and colleagues to visit the clinic, and, most importantly, by paying higher on the sliding scale when economically feasible.This is pretty straight forward and other CA clinics utilize these strategies as well.
What is not perhaps as prevalent is negotiating patient specific payment arrangements.Within reason, WCA allows its practitioners to work with patients to ensure their patients get the number of treatments needed to improve.On any given day, a handful of patients will visit the clinic who have a payment arrangement outside the standard sliding scale, e.g. “Bob” can have unlimited treatments this week with Skip for a flat fee.This is a gift to the patient and allows the acupuncturist to really see results in the patient.Such patients respond with gratitude and an increased commitment to the clinic’s success.Another practical benefit that shouldn’t be overlooked is the fact that the clinic is busier which increases that sense of Social Proof for all patients to witness, “Look at all these people, like me, here for treatment.”As Lisa has clearly outlined in her publication, The Remedy,most patients don’t want charity nor can the clinic afford to give its service away for free, so such payment arrangements are of a temporary nature allowing for patient dignity while allowing for the Rule of Reciprocation to take root in the clinic culture.In short,negotiating temporary payment arrangements with certain patients can be viewed in practical terms as a cost of doing business that will sow the seeds offuture growth in revenue and patient numbers according to the Rule of Reciprocation.
Similar to the concept Social Proof, Cialdini describes the concept of Correct or Unifying Choice which explains that people want to be a part of the correct choice which unifies them with their peers making thesame correct choice.People generally are motivated to be a part of a bigger good choice or action.In my own words, this explains theaverage person’s desire to be altruistic when possible and to take action whenthey see injustice.Tapping into the Correct and Unifying Choice sensibilities of the patient and practitioner community is probably WCA’s greatest achievement.WCA educates patients and practitioners through itspublications, in one-on-one discussions, workshops, through its volunteer program, and through the CAN website about the inequities in health care and the injustices practitioners face in the current system. WCA has successfully defined problems for patients and practitioners and then allows everyone opportunities to be unified and involved in a solution.Activism about social justice is powerful stuff and has helped WCA grow to the astronomical number of 450 patient visits per week.
This success, I believe, can be replicated in other CA clinics with simple tools anda willingness to politicize CA clinics and patient bases.Here are a few suggestions that can aid in tapping into Correct and Unifying choice:
1- Talk to your patients about the issues and what the CAmovement, including patients, is doing to address inequities in health care andthe particular challenges acupuncturists face.
2- Have reading copies of the LittleRed Book of acupuncture for patients as well as The Remedy on hand in the waiting room.Limit other reading material that’seasily on hand.Allow patients to easily gravitate toward literature relevant to the movement.Other health related literature is great, but should not take center stage.
3- Have copies of the aforementioned books for sale in your clinic.
4- Display information on the CAN movement:the mission, other clinics nationwide,the number of patients that are a part of this movement in your community and nationwide.
5- Continue to solicit testimonials from your patient baseand have these readily available on your website and in the clinic as a portion of a newsletter or flier that patients can take with them.
6- Develop your own literature to tap into the activist spirit of your patient community.
7- Allow your patients to help you and be a part of theclinic.Be transparent about your clinic’s progress, challenges and goals with your patients.
Returning to the concept of Social Proof and CA clinics, we defined Social Proof as: when people are uncertain about a course of action, they tend to look outside themselves and to other people around them to guide their decisions andactions.We also saw that outcomes are typically determined by factors such as perception and word choice in are quest or exchange because people want to be a part of a larger group ofpeoples all doing the same thing. I’m advancing for consideration the following claim:the reality of Social Proof comes intoplay every day in multiple exchanges at CA clinics.Specifically, exchanges where Social Proof appears relevantinclude, how much will the patient decide to pay on the self-determined sliding scale, will the patient reschedule, how will the practitioner word a treatment plan for a patient, what word choice will the Reception staff make in regardsto issues of money and patient retention?The cumulative effect of these exchanges and decisions hinging on Social Proof seem to be inexplicably tied to a CA clinic’s success or failure and areworth consideration, experimentation and discussion.
In an effort to establish the desired perception and subsequent decisions, the following suggestions are a good start to capitalizing on Social Proof:
1- Institute or revive a suggested payment amount guide to the self-determined sliding scale.Note somewhere on the guide that, “The suggested payment amounts work for the majority of our patients.”Indicate though that patients can adjust payment according to their individual circumstances.This guide was recently revived at a CA clinic and patients have responded well and the clinic is seeing a wider range of payments along the sliding scale.
2- Ensure reception staff discusses the payment guide, any Financial Policy, and the clinic philosophy with every new patient.Reception staff should point out the benefits of our sliding scale interms of costs savings and access to regular treatment versus the going marketrate.Don’t rely on patients to read the forms.Ask the receptionists to act as a guide for the patient in becoming familiar with the CA model.
3- Your Receptionist, both paid and volunteer, is essential to educating the patient community about the CA philosophy and building relationships with patients.Ensure your reception staff can advocate for the clinic and mission bydiscussing the issues with them and providing relevant reading material.
4- A treatment plan for every new patient should be communicated to the receptionist.As the patient re-enters the reception room, the reception staff will check in with the patient about their experience and suggest rescheduling based on the practitioner’s recommendations.It needs to be communicated by the practitioner or the receptionist that the majority of patients who see results come in frequently, hence the affordable sliding scale.
5- If you use a financial policy to recoup income lost for late cancellations or no shows, allow your reception staff to use their judgment in waiving the associated fees.This is yet another gift to the patient which will benefit the clinic inthe long run based on the Rule of Reciprocation.Being hard nosed about the policy can alienate patients andcreate a sense of scarcity about money and generate an adversarial stance towards patients which won’t benefit anyone.
6- It should be a standard practice to offer booking the next visit each time a patient checks in for an appointment.This shows that it is customary to plan on returning for a treatment the following week, i.e. the patient’s peers booktheir next appointments when they arrive at the clinic.
The work CA clinics do is honorable and such practitioners deserve success and abundance in their practices.I am grateful for the existence of this movement and hope for every CA clinic’s success as this translates into increased access to health care while undermining class divisions in society.It is my sincere hope that the parallels I’ve drawn with the CA modelregarding Social Proof, Rule of Reciprocation, and Correct or Unifying Choice fortifies the CA theory with practical applications that any CA clinic can adopt.
From the August 22, 2008 NPR interview with socialpsychologist and author, Robert B. Cialdini, PhD regarding his new publication,Yes!50 Scientifically ProvenWays to Be Persuasive.