Positive Deviance Research Articles

“Against all Odds”-Increasing Demand and Uptake of Immunization Services Among Non-Fully Immunized Children in Northern Nigeria Using a Positive Deviance Approach: Implementation Science Research

Introduction: Children still die from vaccine-preventable diseases. Nigeria contributes 30% of unimmunized children <5 years globally. This study was conducted in 4 Local Government Areas (LGA) in Niger and Gombe States employing the positive deviance (PD) approach to increase vaccination demand in low child immunization coverage settings. Methodology: The was a quasi-experimental study, conducted between December 2019 and April 2021, comparing pre- and post- intervention vaccination uptake after 5 months of intervention among 400 caregivers of non-fully immunized children (CNFIC). We trained 40 caregivers of fully immunized children (CFIC) as mentors using a participatory learning and action tool. The CNFIC were matched in ratio 10:1 with CFIC and exposed to 8 impact meetings and 10 home-visits using communication materials to increase vaccination knowledge. Paired T-test and adjusted odd ratios from logistic regression models were used to determine change in immunization uptake and factors associated with full immunization for age, respectively. Result: A total of 343 CNFIC were successfully followed up during intervention. The age range of children in the study was 2 to 12 months with the female (178) slightly more than the male (165). The mean vaccine uptake rate increased from 43.7% to 85.9% (T= -29.3, P<0.005) with 55.4% fully vaccinated for age post-intervention. Safer LGA residence, being a housewife caregiver, and younger caregivers <30 years were positive determinants of full vaccination. Conclusion: Adopting the PD approach to low uptake vaccination settings can increase vaccination demand and coverage. This approach can be leveraged in other public health challenges.

Assessing differential gains that outstanding and average performing farmers attain from climate-smart cassava innovations in Nyando climate-smart villages, Kenya

In adoption of agricultural innovations, a few farmers attain outstanding outcomes above their peer majority. This reveals a positive deviance behavior in successful deployment of technologies and innovations. Assessing this behavior in climate-smart agriculture (CSA) can reveal the yield gap in triple wins of CSA (adaptation, farm productivity and mitigation). This study investigated differential gains in these CSA triple wins between outstanding (positive deviants) and average (typical) performing farmers who have adopted climate smart cassava innovations in Nyando Climate Smart Villages (CSV). In a household survey, a sample of 150 farmers were reached, which through snowballing approach, peers identified 30 to exhibit positive deviant behaviour. Presenting these in Focus Group Discussion (FGD) with stakeholders further isolated six farmers being those they consider positive deviants (PDs) in climate smart cassava innovations. Data were subjected to cross-tabulation to generate frequencies used to compute weighted index scores. This revealed increasing magnitude and was a preferred fair comparison of a sample of fewer positive deviants (n=6) with large number of typical (n=144) farmers. Results revealed substantial differences in the attained triple win gains from climate smart cassava innovations between typical and positive deviant farmers. The weighted index scores showed that positive deviant farmers had attained higher adaptability, production diversification, farm productivity and intensification, food security and were implementing more mitigation practices for climate change. This empirical evidence demonstrates potential gains from climate smart cassava innovations when deployed effectively. This is because innovative management practices distinguish positive deviant farmers from typical farmers. These typical farmers would benefit more by learning from positive deviant farmers about effective deployment of climate smart cassava innovations. The study recommends strengthening extension services linked to farmer platforms in order to grow capacity for more effective deployment of climate smart cassava innovations for realising the CSA triple wins. Key words: Adaptability, food security, productivity, production diversification, positive deviants, cassava innovation

The power of positive deviance behaviours: From panic-gogy to effective pedagogy in online teaching.

This study examines university faculty members' successful behaviours and the factors influencing these behaviours, when dealing with the issues posed by emergency remote teaching during the COVID-19 pandemic. Data was gathered through interviews with 12 carefully chosen instructors who competently prepared and implemented their first online classes despite various challenges encountered during the crisis. Interview transcripts were analysed by applying the theoretical concepts of the positive deviance approach to identify exemplary behaviours in the face of crisis. The results revealed that the participants performed three unique but effective behaviours, called 'positive deviance behaviours', in their online teaching: philosophy-driven decision making informed planning and ongoing performance monitoring. These behaviours were affected by individual factors (e.g., community engagement and emotion management during different phases of emergency remote teaching) and organisational factors (e.g., networks/hardware and training/support). By examining the positive deviance behaviours of instructors who delivered effective classes, this study offers online teaching and faculty development strategies in both crisis and non-crisis situations.

Identifying positive and negative deviants and factors associated with healthy dietary practices among young schoolchildren in Nepal: a mixed methods study

BackgroundSchool-based interventions have been implemented in resource-limited settings to promote healthy dietary habits, but their sustainability remains a challenge. This study identified positive deviants (PDs) and negative deviants (NDs) from the control and treatment groups in a nutrition-sensitive agricultural intervention in Nepal to identify factors associated with healthy dietary practices.MethodsThis is an explanatory mixed methods study. Quantitative data come from the endline survey of a cluster randomized controlled trial of a school and home garden intervention in Nepal. Data were analyzed from 332 and 317 schoolchildren (grades 4 and 5) in the control and treatment group, respectively. From the control group, PDs were identified as schoolchildren with a minimum dietary diversity score (DDS) ≥ 4 and coming from low wealth index households. From the treatment group, NDs were identified as schoolchildren with a DDS < 4 and coming from high wealth index households. Logistic regression analyses were conducted to identify factors associated with PDs and NDs. Qualitative data were collected through in-depth phone interviews with nine pairs of parents and schoolchildren in each PD and ND group. Qualitative data were analyzed thematically and integrated with quantitative data in the analysis.ResultsTwenty-three schoolchildren were identified as PDs, and 73 schoolchildren as NDs. Schoolchildren eating more frequently a day (AOR = 2.25; 95% CI:1.07–5.68) and whose parents had a higher agricultural knowledge level (AOR = 1.62; 95% CI:1.11–2.34) were more likely to be PDs. On the other hand, schoolchildren who consumed diverse types of vegetables (AOR = 0.56; 95% CI: 0.38–0.81), whose parents had higher vegetable preference (AOR = 0.72; 95% CI: 0.53–0.97) and bought food more often (AOR = 0.71; 95% CI: 0.56–0.88) were less likely to be NDs. Yet, schoolchildren from households with a grandmother (AOR = 1.98; 95% CI: 1.03–3.81) were more likely to be NDs. Integrated results identified four themes that influenced schoolchildren’s DDS: the availability of diverse food, the involvement of children in meal preparation, parental procedural knowledge, and the grandmother’s presence.ConclusionHealthy dietary habit can be promoted among schoolchildren in Nepal by encouraging parents to involve their children in meal preparation and increasing the awareness of family members.

How positive deviants helped in fighting the early phase of COVID-19 pandemic? A qualitative study exploring the roles of frontline health workers in Nepal.

Positive deviance is an approach wherein learnings from persons who fare better than their peers under similar circumstances are used to enable behavioral and social change. Such behaviors and solutions are likely affordable, acceptable, sustainable, and fit into the socio-cultural milieu. Despite the wide use of positive deviance in many public health programs and research, it has yet to be used to study frontline workers in the context of COVID-19. Therefore, this study aimed to explore the positive deviance traits among frontline health workers during the early days of the COVID-19 pandemic in Nepal. This qualitative study followed a grounded theory approach. The data was collected through in-depth interviews among the 17 identified participants representing different cadres of the health workforce, types of health facilities, and regions across Nepal purposively. The findings are structured around four major themes: challenges, finding solutions and innovations, positive lessons, and motivations. The personal challenges included fear and anxiety about the uncertainties. The professional challenges included stigma, infection control, and changing work style with the use of personal protective equipment. Despite the challenges, they managed available resources and innovated low-cost, technological, and practice-based solutions. They were able to reflect upon the positive lessons learned, such as self-sustainability, teamwork, and policy direction and research, and self-reflection of personal growth and patient care. The intrinsic motivation included their inherent value system, and the extrinsic motivation included appreciation and acknowledgment, family and social support, psychosocial support from peers, and support from higher authorities. This study provides insights into how the positive deviance approach can help identify the solution amid the most challenging circumstances, such as the COVID-19 pandemic in low-resource settings. However, more extensive studies are warranted to explore deeper into positive deviance and its long-term effects in bringing positive outcomes during the pandemic.

Perceptions of Pediatric Endocrinologists and Neurologists on the Drivers of Telehealth Use.

To assess the extent and drivers of telehealth use variation across clinicians within the same pediatric subspecialties. In this mixed methods study, 8 pediatric medical groups in California shared data for eleven subspecialties. We calculated the proportion of total visits delivered via telehealth by medical group for each subspecialty and identified the 8 most common International Classification of Diseases 10 diagnoses for telehealth and in-person visits in endocrinology and neurology. We conducted semi-structured interviews with 32 pediatric endocrinologists and neurologists and applied a positive deviance approach comparing high versus low utilizers to identify factors that influenced their level of telehealth use. In 2019, medical groups that submitted quantitative data conducted 1.8 million visits with 549,306 unique pediatric patients. For 3 subspecialties, there was relatively little variation in telehealth use across medical groups: urology (mean: 16.5%, range: 9%-23%), orthopedics (mean: 7.2%, range: 2%-14%), and cardiology (mean: 11.2%, range: 2%-24%). The remaining subspecialties, including neurology (mean: 58.6%, range: 8%-93%) and endocrinology (mean: 49.5%, range: 24%-92%), exhibited higher levels of variation. For both neurology and endocrinology, the top diagnoses treated in-person were similar to those treated via telehealth. There was limited consensus on which clinical conditions were appropriate for telehealth. High telehealth utilizers were more comfortable conducting telehealth visits for new patients and often worked in practices with innovations to support telehealth. Clinicians perceive that telehealth may be appropriate for a range of clinical conditions when the right supports are available.

Unexpected Successes: Can We Identify Positive Deviance in Surgery?

Unexpected Successes: Can We Identify Positive Deviance in Surgery?

Reducing Overuse by Healthcare Systems: A Positive Deviance Analysis.

Healthcare in the USA is increasingly delivered by large healthcare systems that include one or more hospitals and associated outpatient practices. It is unclear what role healthcare systems play in driving or preventing overutilization of healthcare services in the USA. To learn how high-value healthcare systems avoid overuse of services DESIGN: We identified "positive deviant" health systems using a previously constructed Overuse Index. These systems have much lower-than-average overuse of healthcare services. We confirmed that these health systems also delivered high-quality care. We conducted semi-structured interviews with executive leaders of these systems to validate a published framework for understanding drivers of overuse. Leaders at select healthcare systems in the USA. None APPROACH: We developed an interview guide and conducted semi-structured interviews. We iteratively developed a code book. Paired reviewers coded and reconciled each interview. We analyzed the interviews by applying constant comparative techniques. We mapped the emergent themes to provide the first empirical data to support a previously developed theoretical framework. We interviewed 15 leaders from 10 diverse healthcare systems. Consistent with important domains from the overuse framework, themes from our study support the role of clinicians and patients in avoiding overuse. The leaders described how they create a culture of professional practice and how they modify clinicians' attitudes to facilitate high-value practices. They also described how their patients view healthcare consumption and the characteristics of their patient populations allowed them to practice high-value medicine. They described the role of quality metrics, insurance plan ownership, and alternative payment model participation as encouraging avoidance of overuse. Our qualitative analysis of positive deviant health systems supports the framework that is in the published literature, although health system leaders also described their financial structures as another important factor for reducing overuse and encouraging high-value care delivery.

Adolescent Self-Consent for COVID-19 Vaccination: Views of Healthcare Workers and Their Adolescent Children on Vaccination Autonomy

PurposeThis study explored the perceptions of healthcare worker parents (physicians, nurses, and staff) and their adolescents (aged 12–17 years) on adolescent self-consent to COVID-19 vaccination by applying the concept of positive deviance of those already vaccinated against COVID-19. MethodsWe used a qualitative descriptive design to conduct individual, semi-structured interviews with COVID-19–vaccinated healthcare workers in Southern California and their vaccinated adolescent children. Separate interviews were conducted with parents and adolescents from November to December 2021 using digital phone conferencing software. All interviews were recorded and transcribed. Thematic and constant comparative analysis techniques were used to identify relevant themes and subthemes. ResultsTwenty one healthcare workers (9 nurses, one nurse practitioner, one technologist, and 10 physicians) and their adolescents (N = 17) participated. Three overarching themes were identified to describe participants' perspectives about adolescent self-consent for COVID-19 vaccination: (1) Family values and practices around adolescent vaccination; (2) Differences in parent and adolescent support for vaccine self-consent laws; and (3) Parent and adolescent uncertainty on readiness for vaccine self-consent laws. Adolescents largely supported self-consent while parents supported the policy if they would be able to have a discussion with their adolescent prior to the decision. DiscussionParents and adolescents supported adolescent self-consent for COVID-19 vaccination, with the reservation that adolescents should discuss the decision alongside their parents to exercise their medical autonomy with supportive guidance. Greater adolescent involvement in making decisions and providing self-consent for healthcare, including vaccines, could prepare adolescents to have a greater sense of autonomy over their health and contribute to population health measures.

IDENTIFYING CLIMATE-RESILIENT AGRICULTURAL PRACTICES IN INDIA THROUGH POSITIVE DEVIANCE ANALYSIS OF SOIL MOISTURE, TEMPERATURE, AND PRECIPITATION ANOMALIES IN TELANGANA

This study presents a analysis of the impact of climate change on several factors that affect agricultural output such as soil moisture, temperature anomalies, and precipitation anomalies. The project utilizes data-powered positive deviance (DPPD) to identify farmers who are achieving better values of the aforementioned factors despite similar geographical conditions. The findings are then used to devise policies to assist other farmers in adopting similar practices. The methodology used in the study applies seasonal-trend decomposition using the loess (STL) method to analyze temporal trends of weather variables across a specific region, using data collected from various sources, such as satellite imagery and weather station readings in the state of Telangana. Similar studies done across the world demonstrate an improvement in crop yields and an increase in the resilience of farms from rapid climate change.

Urban-rural differences in the relationship between stunting, preschool attendance, home learning support, and school readiness: A study in Côte d'Ivoire.

Stunted physical growth during early childhood is a marker of chronic undernutrition, and the adverse life circumstances that underlie it. These have the potential to disrupt normal brain development and the acquisition of foundational cognitive, language, social and motor skills. Stunting is prevalent in most low-and middle-income countries. Because the prevention of stunting requires large-scale structural and attitudinal changes, several psycho-educational interventions have been developed to mitigate the adverse association between early stunting and skill development. However, the resource-intensive nature of custom-designed interventions limit their sustainability and scalability in resource-limited settings. This study explored the possibility that available resources that promote positive development (existing preschool education programs, and no- or low-cost home-based learning activities and resources) may protect against any negative association between stunting and the acquisition of foundational skills required for academic learning and adaptation at school. Data for 36-to 59-month-old children (n = 3,522; M = 46.7 months; 51.2% male; 74.1% rural) were drawn from the most recent Multiple Indicator Cluster Survey conducted in Côte d'Ivoire (MICS5, 2016). Stunting was assessed using the WHO Child Growth Standards. Preschool attendance and home learning activities and resources were assessed by maternal report. School readiness was assessed using the 8-item form of the Early Child Development Index (ECDI). A high percentage of children met the criteria for stunting (28.5%; 19.7% moderate; 8.8% severe). There were marked urban-rural differences in the prevalence of stunting, rates of preschool attendance, home learning activities and resources, children's school readiness scores, and the relationships between stunting, the protective factors and school readiness scores. These urban-rural differences in ECDI scores could be fully explained by differences between these settings in stunting and the protective factors. However, only two protective factors (access to books and home-based activities that promote learning) made independent contributions to variance in ECDI scores. There was tentative evidence that stunted children whose homes provided highly diverse learning activities and multiple types of learning resources were more likely than those who did not to have a high level of school readiness. Capitalizing on the existing practices of families that show positive deviance in caregiving may provide a basis for culturally appropriate, low-cost interventions to improve school readiness among children in low- and middle-income countries, including children with stunted growth.

Use of multidisciplinary positive deviance seminars to improve efficiency in a high-volume arthroplasty practice: a pilot study.

Positive deviance (PD) seminars, which have shown excellent results in improving the quality of surgical practices, use individual performance feedback to identify team members who outperform their peers; the strategies from those with exemplary performance are used to improve team members' practices. Our study aimed to use the PD approach with arthroplasty surgeons and nurses to identify multidisciplinary strategies and recommendations to improve operating room (OR) efficiency. We recruited 5 surgeons who performed high-volume primary arthroplasty and had participated in 4-joint rooms since 2012, and 29 nurses who had participated in 4-joint rooms and in at least 16 cases in our data set. Three 1-hour PD sessions were held in February and March 2021: 1 with surgeons, 1 with nurses, and 1 with both surgeons and nurses to select recommendations for implementation. The sessions were led by a member of the nonorthopedic surgical faculty who was familiar with the subjects discussed and with PD seminars. To determine the success of the recommendations, we compared OR efficiency before and after implementation. We defined success as performance of 4 joint procedures within 8 hours. Eleven recommendations were recorded from the session with nurses and 7 from the session with surgeons, of which 11 were selected for implementation. During the month after implementation, there were great improvements across all time intervals of surgical procedures, with the greatest improvements seen in mean anesthesia preparation time in the room (4.51 min [26.3%]), mean procedure duration (9.75 min [14.0%]) and mean anesthesia finish time (5.78 min [44.0%]) (all p < 0.001). The total time saved per day was 49.84 minutes; this led to a success rate of 69.0%, a relative increase of 73.8% from our 2012-2020 success rate of 39.7% (p < 0.001). The recommendations and increased motivation owing to the individualized feedback reduced time spent per case, allowing more days to finish on time. Positive deviance seminars offer an inexpensive, efficient and collegial means for process improvement in the OR.

Multicentre positive deviance to reduce adverse events and length of stay after pulmonary resection

BackgroundPostoperative adverse events (AEs) following pulmonary resection enormously impact patient well-being, length of stay (LOS) and healthcare costs. Standardised AE data collection can be used to identify positive outliers demonstrating...

Characteristics of High Versus Low-Performing Hospitals for Very Preterm Infant Morbidity and Mortality

To ascertain organizational attributes, policies, and practices that differentiate hospitals with high versus low risk-adjusted rates of very preterm neonatal morbidity and mortality (NMM). Using a positive deviance research framework, we conducted qualitative interviews of hospital leadership and frontline clinicians from September-October 2018 in 4 high-performing and 4 low-performing hospitals in New York City, based on NMM measured in previous research. Key interview topics included NICU physician and nurse staffing, professional development, standardization of care, quality measurement and improvement, and efforts to measure and report on racial/ethnic disparities in care and outcomes for very preterm infants. Interviews were audiotaped, professionally transcribed, and coded using NVivo software. In qualitative content analysis, researchers blinded to hospital performance identified emergent themes, highlighted illustrative quotes, and drew qualitative comparisons between hospital clusters. The following features distinguished high-performing facilities: 1) stronger commitment from hospital leadership to diversity, quality, and equity; 2) better access to specialist physicians and experienced nursing staff; 3) inclusion of nurses in developing clinical policies and protocols, and 4) acknowledgement of the influence of racism and bias in healthcare on racial-ethnic disparities. In both clusters, areas for improvement included comprehensive family engagement strategies, care standardization, and reporting of quality data by patient sociodemographic characteristics. Our findings suggest specific organizational and cultural characteristics, from hospital leadership and clinician perspectives, that may yield better patient outcomes, and demonstrate the utility of a positive deviance framework to center equity in quality initiatives for high-risk infant care.

Analyzing antifragility among smallholder farmers in Bihar, India: An assessment of farmers’ vulnerability and the strengths of positive deviants

Summary Farmers around the world are increasingly vulnerable: climate variability is identified as the primary stressor, but unfavorable biophysical circumstances and disturbances in the socioeconomic domain (labor dynamics and price volatility) also affect farm management and production. To deal with these disturbances, adaptations are recognized as essential. Antifragility acknowledges that adaptations and volatility are inherent characteristics of complex systems and abandons the idea of returning to the pre-disturbance system state. Instead, antifragility recognizes that disturbances can trigger reorganization, enabling selection and removal of weaker system features and allowing the system to evolve toward a better state. In this study, we assessed the vulnerability of different types of smallholder farms in Bihar, India, and explored the scope for more antifragile farming systems that can ‘bounce back better’ after disturbances. Accumulation of stocks, creation of optionality (i.e., having multiple options for innovation) and strengthening of farmer autonomy were identified as criteria for antifragility. We had focus group discussions with in total 92 farmers and found that most expressed themselves to be vulnerable: they experienced challenges but had limited adaptive capacity to change their situation. They mostly made short-term decisions to cope with or mitigate urgent challenges but did not engage in strategic planning driven by longer-term objectives. Instead, they waited for governmental support to improve their livelihoods. Despite being confronted with similar challenges, four positive deviant farmers showed to be more antifragile: their diverse farming systems were abundant in stocks and optionality, and the farmers were distinguished in terms of their autonomy, competence, and connectedness to peers, the community, and markets. To support antifragility among regular farmers, adaptations at policy level may be required, for example, by shifting from a top-down toward a bottom-up adaptation and innovation regime where initiative and cooperation are encouraged. With a more autonomous orientation, farmers’ intrinsic motivation is expected to increase, enabling transitions at the farm level. In this way, connected systems can be developed which are socioeconomically and biophysically adaptive. When practices, knowledge, and skills are continuously developed, an antifragile system with ample stocks and optionality may evolve over time.

Data-Powered Positive Deviance: Combining Traditional and Non-Traditional Data to Identify and Characterise Development-Related Outperformers

Data-Powered Positive Deviance: Combining Traditional and Non-Traditional Data to Identify and Characterise Development-Related Outperformers

A cross-sectional study on factors associated with health care seeking for acute respiratory infection and fever in children under-five in Zambia.

mortality in under-five children remains a significant challenge in developing countries, including Zambia, where pneumonia and malaria account for twenty percent of under-five deaths. Poor health care seeking is one of the contributors to the high mortality rates. This study examined the predictors of health care seeking for acute respiratory infection (ARI) and fever among under-five children in Zambia. the study used a population based cross-sectional survey program evaluation dataset with sample size of 12,507 households from 28 districts. Binary logistic regression was used to examine the determinants of appropriate care seeking for ARI or fever, ARI, and fever. the prevalence of fever or ARI in children under five was 22.9%, ARI 12.9%, and fever 13.4%. Educational status and non-participation in positive deviance hearth (PDH) were significant predictors in those with fever or ARI. Children whose household head had secondary education or higher were 4.5 times more likely to seek care than those whose household head did not have any education. Among those with ARI, educational status, women empowerment in decision-making and growth monitoring and promotion (GMP) were significant predictors while for fever only GMP was a significant predictor. over two thirds of caregivers sought care appropriately for fever or ARI. Only educational status and GMP were associated with more than one appropriate care seeking outcome. Through GMP services, policymakers can improve healthcare seeking behavior in children under five.

Dynamic Self-Determination of Self-Care and Positive Deviance Model for Stunting Prevention in Indonesia

Dynamic Self-Determination of Self-Care and Positive Deviance Model for Stunting Prevention in Indonesia

Coping with eco-anxiety: An interdisciplinary perspective for collective learning and strategic communication

Anthropogenic climate change and ecological crisis are affecting people's mental health. One such manifestation, eco-anxiety, is anxiety in the form of negative, troublesome, and automatic physiological, cognitive, emotional, and behavioral reactions to climate change and ecological degradation. The speed, scale, and severity of unfolding environmental crises will continue to exacerbate experiences of eco-anxiety. Scholars and practitioners are still in the early stages of understanding and addressing the phenomenon. To help prioritize future endeavors, we advocate for an interdisciplinary approach to address the urgency and complexity of eco-anxiety, which can be understood in the context of a larger problem facing humanity. We provide an eco-anxiety primer based on recent scoping reviews and seminal empirical research. Additionally, we recommend four opportunities for collective learning and strategic communication: (1) motivational and actionable message framing, (2) storytelling for social and behavior change, (3) knowledge sharing and linked resources, and (4) positive deviance for complex problem-solving. We hope this article will benefit health practitioners, media professionals, academic researchers, policy makers, community leaders, climate activists, and other stakeholders.

Classic Text No. 133: 'Maxwell Jones and the Therapeutic Community', by David Millard (1996).

This text was David Millard's departing gift to a field to which he had contributed for 30 years, as practitioner and later as Lecturer in Applied Social Studies and editor of the International Journal of Therapeutic Communities. Charting the chronology of Maxwell Jones's career as a world-renowned psychiatrist and therapeutic community pioneer, Millard contrasts Jones's contribution at Mill Hill with Tom Main's at Northfield. Jones's most distinctive contribution was allowing patients to become auxiliary therapists and freeing nurses from the nursing hierarchy. Focusing on a subset of therapeutic communities in adult psychiatry, Millard's paper is not an academic history of therapeutic communities as such. The roles of happenstance and positive deviance are demonstrated in the way change occurs in therapeutic communities. The 'charisma question' is briefly explored.