Conceptualizing the Carrying Function of Community Advisory Boards

Abstract

Community Advisory Boards (CABs) often, “carry” important ideas and concepts for the larger organization of which they are a part. The word “carry” in this context, means that a person or group expresses verbal and nonverbal messages that inform others of what the institution acknowledges, and also what it cannot bear to feel or talk about. These expressions may include attitudes and expectations, values, risks, or disowned features and qualities. A group can contain, “carry,” and express formal, informal, and unconscious issues for a department or system. In this article, we situate our theoretical underpinning of this carrying function by relying on a number of literatures: identified patient, splitting and projection, parallel process, and container and contained. Specifying and examining the dynamics of what CABs carry for an institution can prevent common pitfalls for these groups, such as mistrust, feelings of disrespect, lack of productivity, and thwarted expectations.

Community Advisory Boards (CABs) are increasingly used by researchers within hospital systems and other large organizations to provide patient perspectives about healthcare processes and outcomes. Boards are called upon to address a range of issues from how to make a clinic more welcoming; their preferences regarding care coordination and treatment; and even difficult topics, such as racist and sexist experiences at the hands of their providers (Cramer et al., 2018; Forsythe et al., 2019; Frye et al., 2015; Joosten et al., 2015; Morin et al., 2003; Pinto et al., 2011; Safo et al., 2016; Silvestre et al., 2010; Walsh et al., 2015; Young et al., 2019). The ability of CABs to surface community concerns, such as environmental degradation, clinical care miscues, psychosocial stressors, or other socially determined factors at work in medical research and related quality improvement efforts, has received attention in the literature (National Academy of Sciences, Engineering, and Medicine (NASEM), 2017). However, the immensely social and relational nature of the work of CABs is often underestimated. The focus of the literature about CABs is typically on the actions, behaviors, and recommendations that CABs provide rather than the psychology that underpins and sustains these relationships (Clark & Friedman, 2021; Newman et al., 2011; Walsh et al., 2015). The psychodynamic literature offers clusters of constructs that enable us to explain the psychological and behavioral features of CABs (Petriglieri & Petriglieri, 2020). To add another layer to what we know about CABs, we have noticed from our own experiences that these groups are quite often being asked to “carry” important concerns such as expectations, values, difficult conversations, risks, or disowned features of the larger organizations of which they are a part. “Carry,” in this context, means verbal and nonverbal messages that inform others of what the institution acknowledges, and also what it cannot bear to feel or talk about (Jaques, 1953; Petriglieri & Petriglieri, 2020; Riesenberg-Malcolm, 2009; Rosenbaum & Garfield, 1996). Often, a conflicted element of the organization, representing a mixture of contradictory feelings and attitudes, has been given into the custody of the CAB.

To the degree that a department, panel, or sub-group of an institution has not acknowledged that they are being asked to carry an aspect of the establishment's functioning, the effectiveness of the group and the institution may be curtailed. For example, oftentimes organizations create committees or task forces without granting them the power to address the troubles or inefficiencies they uncover (Argyris, 1990, 1993; Brown, 2021; Manzoni & Barsoux, 1998; Mitchell, 2020). Therefore, we argue, it is important to initiate discussions about the feelings, performative roles and positionality a CAB may be asked to carry. These concerns may be explicit (e.g., sharing their care experiences), taken-for-granted (e.g., continually offering creative solutions), and/or unacknowledged (e.g., surfacing taboo organizational issues). By specifying and examining the dynamics of what CABs carry for an institution, we believe that common pitfalls may be avoided, such as mistrust, feelings of disrespect, lack of productivity, thwarted expectations, and ultimately regression, dysfunction, and failure of the CAB's mission. Furthermore, when CABs understand what they are carrying, they can become skillful and authentic advocates for the communities they represent. We demonstrate here that when these hidden aspects are acknowledged openly, there is more likelihood that a CAB will function with autonomy, agency, and effectiveness. Through a combination of hypothetical and fictional examples, as well as descriptions of behaviors that research suggests are likely to happen, we present frameworks through which we interpret what we have observed from our own work with CABs.

Background

Our CAB is one of several within the Veterans Health Administration (VHA). The VHA within the US Department of Veterans Affairs (VA) is unique: VHA is a healthcare system designed to serve a citizen group who have had a collective experience. It is a nationwide integrated chain of 171 hospitals that oversee a further 1,269 satellite outpatient sites of care, serving a diverse population of ∼9.6M Veterans (Department of Veterans Affairs, 2022). Therefore, in accordance with competencies and characteristics described in VA's Core Values, the VHA must remain open and responsive to the unique views, experiences and needs of the Veteran (Department of Veterans Affairs – I CARE, 2022).

In addition to its healthcare function, the VHA has a long history as a leading biomedical research institution, responsible for some innovations and advancements in US medical care that are now ubiquitous: the pacemaker, the nicotine patch, the CT scan, and the first electronic medical records (Office of Research and Development (ORD) Timeline, 2022; Allen, 2017). However, VHA remains subject to the same institutional norms that plague any large organization, such as difficulty incorporating innovation, trouble modernizing systems and priorities in a timely way, and slow uptake of diverse perspectives and opinions (Hausmann et al., 2020; Olenick et al., 2015; Rein, 2022; Schön, 1970). This, in combination with senior leaders who are in a position to guide change but who remain invested in the system as is, often results in organizations that are very slow to change (Argyris, 1990; Pfeffer, 2015). Moreover, research institutions, which are thought of as points of rigorous innovation, can also be subject to institutional complacency, inequity, and backwardness (Bellett, 1992).

Bringing their diverse voices and new perspectives to a research organization like the VHA, CABs personify disequilibrium and will raise issues and questions that are destabilizing and uncomfortable for an institution. As a force for growth, CABs also embody as much creativity as an organization will allow. They “carry” re-invention and reform; CABs may also be thwarted by an institution's “dynamic conservatism,” its entrenched adherence to the status quo (Schön, 1970).

The “Carrying Function”: What Do Groups Carry?

Although what a group “carries” for a department or organization is familiar to those who study group relations, intergroup and system dynamics, it has yet to be discussed in relation to CABs. As a part of the effort to describe what we are observing with our VHA CAB, we use here the word “carry” to denote the cognitive and emotional act of holding ideas, thoughts, and emotions in the consciousness of a person or a group. Because we have not identified an existing single framework that adequately summarizes our experiences, this section explains the multiple frameworks we employ to make sense of this carrying process for CABs.

It important to note that we start with the assumption that groups in an organization often mirror the aspirations, achievements, distortions, and deficiencies of the larger organizational system (Agazarian, 1989; Bloom, 2010; Smith & Crandell, 1984; Smith & Zane, 1999). Microcosm groups (Smith et al., 1989), in which representatives of every major institutional component are brought together, are an especially good example of how a group can contain, carry and express formal, informal, and unconscious issues for a department or system. With this in mind, we present a number of fictive examples to situate our theoretical underpinning of the carrying function. We have relied on a number of literatures: identified patient, splitting and projection, parallel process and container and contained.

Identified Patient

The “identified patient” literature from family systems therapy (Boverie, 1991; Ettin, 2000; Ferenchick & Rosenthal, 2017) provides the fundamentals for seeing a group as carrying something for the larger entity of which it is a part. In the family systems model, the identified patient often bears a behavioral dysfunctional pathology for a whole family. Conversely, a successful family member may carry accomplishments, while the family acts as though the heroic member is the only one who has succeeded. In both cases, the identified patient or the identified hero carries a psychological attribute, dysfunction, or accomplishment for the family as a whole. The individual and the family behave as if the dysfunction or accomplishment belongs solely to that family member, rather than to the family system – a system that has nurtured and modeled the behaviors of all its members (Agazarian, 1989; Boverie, 1991; Ettin, 2000; Ferenchick & Rosenthal, 2017). As a consequence, there may exist unspoken, or unconscious, expectations or frames that a family holds toward each member. For example, a mother, perceived as unusually attentive and anxious, may be blamed for often scuttling family adventures. It is very possible, however, that the mother is carrying anxiety for the family, freeing up other family members to behave as if their mother is the anxious one and they are not, and allowing feelings of resentment to ensue.

When the identified patient processes are applied to the analysis of group-level functioning, groups may carry aspirations, problems, and dysfunctions for a department or system: the department or system acts as though the accomplishment or problem belongs to the group alone (Ettin, 2000). In the case of CABs, it may be helpful to envision the interpersonal behaviors between CAB members as akin to those of siblings or teammates, while the leaders in the institution may behave in a parental fashion. In these instances, familial relationships may be reenacted. Organizational members therefore often replay in their work settings the family dynamics they experienced growing up (Hirschhorn & Gilmore, 1980).

Splitting and Projection

The “carrying function” may be further revealed through the psychodynamics and behaviors of splitting, and projection. As a defense mechanism, organizational groups split off unacknowledged parts of themselves onto other groups (Dunning et al., 2005; Horowitz, 1977; Jacques, 1953; Lewis et al., 1994; Pellegrini, 2010; Schein, 1989; Smith & Berg, 1987). A group may split off portions of its behavioral or emotional life that induce internal conflicts or provoke anxiety (Jacques, 1953; Schein, 1989). For example, a leadership group in an organization may refuse to acknowledge mistakes. Even though it is as prone to errors as any other group, it instead splits off parts of any functioning that it disowns, such as acknowledging mistakes, and assigns blame for errors to other groups. In this way, the leadership group is protected from acknowledging its own weaknesses or problems and can enjoy feeling superior to its subordinates, who are now regarded as mistake prone.

When a leadership group splits off an uncomfortable denied aspect, it is likely, as noted above, to project it onto another group. Alternatively, groups in organizations may also split off unacknowledged positive behaviors and project those onto another group. For instance, a group of direct reports to a leadership team may split off and project its competence onto another group. One of these competing groups is likely to succeed at the expense of the other, with both groups experiencing unjustified feelings of superiority or inferiority, respectively (Schein, 1989). The latter group may then claim to be effective and authoritative, and the former group may complain of lack of power and being under-resourced.

In a further example, over time a group of leaders working with a CAB may split off and project their unacknowledged arrogance onto a CAB. As a result, a CAB's behavior comes to be viewed as defensive, grandiose and intransigent. Through the dynamics of splitting and projection, which are often unrecognized, a CAB may be the recipient of anxiety-producing split-off thoughts and emotions (Akhtar & Byrne, 1983; Dunning et al., 2005; Murstein & Pryer, 1959; Pellegrini, 2010). Conversely, positive projections may also be split off by leadership onto a CAB, such as the ability to frankly discuss ageism or homophobia in-depth. Although the CABs’ interactions may reflect and reciprocate these positive projections, they minimize leadership's involvement. Likewise, owing to the CABs willingness to openly discuss participant perspectives, it may be unconsciously viewed as better equipped to handle difficult conversations and subjects, material which may become burdensome and limiting for CAB members. Later in this paper we will highlight some of the unconscious projections we have witnessed.

A further problem may develop when a group does or does not internalize a projection. Nonetheless, research tells us that because of anxiety, leaders may still experience a CAB as carrying negative thoughts and feelings and may act as though their projections are accurate (Jacques, 1953; Lewis et al., 1994; Smith & Berg, 1987; Wells, 1980). A CAB, as the recipient of the unwelcome and presumptuous projection from leadership, may act in ways that maintain its boundaries such as articulating and countering the unwanted projection. Or, the CAB may adopt the unwanted projections (i.e., projective identification) and behave in an angry, self-righteous, and arrogant manner (Brown et al., 2020; Smith & Berg, 1987; Wells, 1980). In instances such as these, the CAB might act in ways that confirm the projection of the leadership. An unintended consequence of all of these behaviors for the CAB is that it may become the target of distorted and unacknowledged thoughts and feelings with which leadership is operating.

Parallel Process

Studies of parallel process (Bloom, 2010; Smith & Berg, 1987; Smith & Crandell, 1984; Smith et al., 1989; Smith & Zane, 1999) indicate that groups often mirror intentions, concerns, and conflicts occurring in the organization (Smith & Berg, 1987; Smith & Zane, 1999). For instance, if a hospital system has established clinical pathways that embrace creative and innovative thoughts and solutions, a CAB may likewise reflect this creativity and innovation in its deliberations. Too, if the system is highly bureaucratic, the CAB will be prone to bureaucratic behaviors. Because group conduct mirrors their larger organization (Smith & Zane, 1999; Sullivan, 2002), it is important that a CAB and its supporters have a comprehensive awareness of overt, informal, and covert issues (e.g., institutional successes, shortcomings, or leadership failures), so that its functioning does not get stuck in solely mirroring the system's inadequacies or failures. Most importantly, CABs need to notice when this negative mirroring is happening.

Container and Contained

Bion's model of container and contained is important for our analysis. This model arises from group psychoanalytic sessions where difficult feelings are expressed (Billow, 2000; Bion, 1959/1961, 1985; Diamond, 1998; James, 1984; Riesenberg-Malcolm, 2009; Stiers, 1995; Weightman & Smithson, 2019). Within focus groups, for instance, the moderator (the container) must allow participants to express their views without becoming angered or defensive as a result (Krueger & Casey, 2015). Especially with difficult conversations, which involve the mediation of hard feelings, the moderator must contain the feelings without falling prey to the feelings themselves, demonstrating through their actions that a more integrated and developmentally appropriate response is feasible (Billow, 2000; Bion, 1959/1961, 1985; Diamond, 1998; James, 1984; Riesenberg-Malcolm, 2009; Stiers, 1995; Weightman & Smithson, 2019). The focus group members (the contained), in turn, are able to discuss difficult matters without fear of dysfunctional interactions. Therefore, container and contained characterizes emotional “nestings” that alternate (Billow, 2000; Bion, 1959/1961, 1985; James, 1984; Rosenbaum & Garfield, 1996; Stiers, 1995). A group leader (serving as a container), shifts between harbor and confrontation roles, sitting with discomfort for a time rather than dispelling or disengaging from difficult feelings. This is done in order to raise the group's effectiveness. “On the interpersonal level, the pair and group serve as container, while public expressions of the individual—symbols, emotions, thoughts, self-presentation, and action—are contained. The nesting process is a developmental achievement” (Billow, 2000, p. 246).

In sum, the concepts and models described in this section give us a vocabulary in which to situate our own observations. These concepts pinpoint the full spectrum of roles and behaviors that CABs enact both consciously and unconsciously. Furthermore, it is in combining these respective models that the uniqueness of what we have observed with CABs in biomedical research settings becomes apparent.

Carrying Function: Performed

Building on behaviors and frameworks that we talked about above, we turn now toward a fictive example of how a carrying function may be performed by an advisory panel in an organization. First, a panel may have an official role that it enacts. Our hypothetical group will be officially designated as the diversity and inclusion committee for a department in an organization, charged with improving specific plans and support for employees. In this case, the group would have the responsibility of ensuring that the department attracts and retains a diverse work force, reflecting the aspirations of its community. Second, in addition to this formal responsibility, the diversity group might have been told informally by their superiors to advocate for promoting from within. Third, the unspoken expectations for this diversity group may be that they will enforce company cultural norms regarding new employees and their introduction to the company.

This fictional diversity team is positioned within a net of responsibilities, values, and expectations, some of which are positive and helpful, and some less so. Responding to the needs of their superiors is a beneficial responsibility, value, and expectation. However, this hypothetical team also recognizes that leadership has not acted on prior recommendations to improve diversity in the workforce. Because the organization's leaders have not been willing to own their part in exemplifying and promoting diversity, this scenario is also an example of splitting. Moreover, some of these values above are clearly and formally presented to the team, others are informal while still others remain obscure. Promoting from within could be a positive expression of the company's philosophy, for example. However, here it is presented as an informal expectation with no authority to back up its execution. The diversity team is responsible for executing the organization's desire for diversity and inclusion without falling prey to the leadership's resistant feelings and behaviors about diversity, an example of the container and contained.

If the imaginary diversity team explicitly points out negligence or shortcomings of the organization, as in our examples above, it is not unexpected that this will make leadership uncomfortable. The diversity team may experience reprisals such as being patronized, tokenized, or their recommendations dismissed, such as recently occurred at Google (Solon & Glaser, 2020). This alienating treatment of a team may have destructive consequences.

On the one hand, we suggest that advisory boards like our diversity task force carry affirmative values, such as embodying the positive outcomes that an organization views as a success. Similar to the hero in the identified patient literature, the task force fights for constructive suggestions and improvements for the organization and is also an example of positive projection. On the other hand, the diversity task force may carry complex, even onerous, values and behaviors that the organization prefers not to deal with: the occasional sexually harassing or racist remark, or insensitivity toward those with disabilities. In the face of troubling interactions like these, an organization may become passive, hoping that others like those on the diversity task force will point the way toward addressing it (e.g., policing sexual harassment, countering racism, adapting to workers with disabilities, etc.). Often, the behavior of pressing these more difficult aspirations onto a group, an example of splitting and projection, may be accompanied by delay and handwringing by the organization as it moves toward contending with what the task force has uncovered.

The situation is even more tenuous when the responsibilities, values, and expectations of our hypothetical task force are disowned or unconscious within the organization. An example of these attributes could be the organizations history of profiteering from the exploitation of marginalized and racialized groups (Smith et al., 2003). One outcome of this blind spot for the organization can be that systems, organizations, and departments may ask the diversity team to carry issues and feelings that they want to bury, don't know how to cope with, or are ambivalent about. Sometimes, the impetus to create a task force has to do with the organization's desire to flee from an issue, to avoid it. When this happens, and if the diversity task force takes up the issue, research tells us that the organization can then blame the task force for being tactless, aggressive, rebellious, etc., satisfying the organization's desire to disown the issue (Argyris, 1990; Diamond, 1998). A casual reference to a system's inequitable outcomes by a task force member, for example, may give rise to a defensive, blaming response from system leaders, a sign of unconscious anxiety and avoidance surrounding known system failures, and an ambivalent response to those failures. Leaders may become as tactless and rebellious as they are accusing the diversity task force members of being. Alternatively, at times an organization will ask a task force to carry an issue that it is merely uncertain how to deal with, harboring the hope that the group will help them to understand and cope with the issue (what we call “mothering” toward containment) (Bion, 1959/1961; Wells, 1980). When this occurs, the organization is operating in a positive, albeit unconscious mode, and is open to learning from the group.

Still, the organization's ambivalence about an issue it asks a task force to carry may play out in several ways. The organization may start debating or resisting the way a task force is examining and dealing with an issue. In this instance, the task force is being asked covertly to become oppositional to what the organization is espousing (Diamond, 1998). When this happens, there is little chance of integration, as the organization will use the team to get rid of its ambivalence in an either/or choice. Another more favorable possibility is that when the organization asks the task force to carry its conflicted feelings, it may then be able to see that it needs to integrate rather than disown what the task force is carrying. There remains always the possibility of denial, splitting and projection or integration when a team is asked to carry an issue for the larger organization (Smith & Berg, 1987).

While not everything an organization places into the care of an advisory panel like our fictive diversity task force is unwelcome, how the ideas, behaviors, and concerns are actualized—if these values and expectations are formally acknowledged versus unspoken by the institution—may become problematic. Now we will turn to real world examples of both receptivity and discomfort with what an advisory panel may uncover.

Carrying Function Performed: An All-Veteran CAB

In setting up a Veteran CAB for our research center and enabling the members to give input to investigators, their formal role was to: (1) represent the Veteran community regarding care experiences at VA; (2) provide their health-related preferences, and (3) to devise ways to act upon those experiences and preferences. Our Center is one that specializes in health equity for Veterans and specifically researches ways to improve healthcare delivery for underserved and marginalized Veteran subgroups (e.g., LGBTQ+ Veterans, women Veterans, native American Veterans, Veterans over 65, Veterans experiencing homelessness, and Veterans with serious mental illness, etc.). Our CAB, which is composed of members from these subgroups, took on its advocacy role willingly. Our Center receives several important benefits from this relationship: research appears more responsive to the needs of Veterans and to the health system, and research innovations are thus more likely to be implemented sooner (Clinical and Translational Science Awards Consortium (CATSAC), 2011). As a consequence, in engaging Veterans as partners, our center commissioned them to formally carry multiple attributes associated with seeking care at the VA. These features may be described as both positive and negative.

First, let us describe the membership and selection criteria of our CAB. As we published in our 2020 article (Brown et al., 2020), we convened two focus groups in which Veterans receiving care at our facility came together as equals with our Center's Principal Investigators (PIs) to discuss CAB formation. Running focus groups allowed us to model the inclusive listening that we hoped the CAB would adopt. We selected researcher participants for the focus group who had experience with community-driven research, as this group would be more likely to value community perspective. Similarly, Veterans were recommended to us by clinicians on account of their willingness to discuss their care in an open and assertive manner. The ability to raise difficult or controversial issues without judgment was also highlighted. There was agreement that CAB members should be oriented toward service and helping the Center's work, rather than any personal benefit.

Based on other CAB models, we decided that the CAB would have a Chair and Vice-Chair. Our selection criteria for these posts were that the candidate should have prior community engagement experience, clear grasp of research principles, and an extensive connection to the Veteran community at large. The CAB Chair and Vice-Chair assumed responsibility for the selection of the other members, who included Veterans who get their care at VA and those who do not, as well as Veterans who are employed by VA. Important in the selection process was the notion that members of the Board reflect the vulnerable populations essential to the Center's research mission, such as Veterans experiencing homelessness, justice-involvement, substance use, and disparities owing to social determinants of health. The authors’ decided to take a back seat during the selection process, an unusual and deliberate step, as research center staff and PIs often make all initial decisions about CAB formation, including membership (Pinto, Spector & Valera, 2011; Wendleton et al., 2019). This first iteration of the CAB was composed of 11 members.

From our direct experience and group and organizational research (Brown et al., 2020; Maxwell et al., 2022), we also decided to restrict CAB members to Veterans and spouses/caregivers. By doing so, we believed the group cohesion would be enhanced by: (1) helping group members experience their own agency, which is more likely to occur when everyone in the group has the same status and power; (2) strengthening the CAB's ability to challenge power differences between patients and PIs; and (3) enabling the entire CAB to confront the PIs’ greater expertise, and reduce the tendency of PIs to dominate conversations about research (Newman et al., 2011). We hoped to avoid the splintering into factions we had witnessed with other advisory boards and committees that included patients and PIs, with the PIs holding the upper hand and the patients’ voices being sidelined (Hahn et al., 2017; Newman et al., 2011; Ocloo & Matthews, 2016; Pinto et al., 2013; Safo et al., 2016).

At times, Veterans seeking care at the VA are in good health and are functioning and contributing members of our society. At other times, Veterans may struggle with addiction, depression, homelessness, and gender and racial disparities, alongside greater rates than the general US population of just about every morbidity (Saha et al., 2008; Betancourt et al., 2021). Our Veteran partners in the CAB carry these diverse qualities and features whether or not a health status is stigmatized, related to past trauma, or any other concern that might make a Veteran feel vulnerable. Though initially, this carrying function of their work was unconscious, as their competency has grown, our CAB's awareness of this more difficult, proxy component of their formal role has become emphasized.

The informal behaviors and features of our CAB's role stem from responsibilities, expectations, and values that were not codified in their original foundation. Our CAB was chartered to engage Veterans in providing information about their health-related experiences and preferences (Brown et al., 2020). However, our CAB has also acted to fill gaps in our existing research infrastructure, a completely informal role, as these activities were never explicitly listed in their founding documents, although consistent with their mission. Gaps that Veterans identified were in how patients were approached as potential research participants, compensation amounts, ways to learn about active studies, how to have respectful conversations during the consenting process, and the ability of Veterans to access the results of studies. These informal initiatives exemplify the ways in which research leadership had not taken responsibility for the overall social experiences Veterans have when they are engaged in research. The CAB's desire to advise not just at the project level but at the center level, to perform consistent community outreach and education, to accept shared leadership roles in projects with PIs and the facility, and to upgrade the processes of recruitment represents how informal behaviors and expectations may accrue to a CAB. Interestingly, these informal expectations are also the settings most empowering for the CAB, enabling them to make impactful decisions that stretch beyond the traditional role of “Consult” as seen in the Community Engagement Continuum (Brown et al., 2020; CATSAC, 2011; Hyde et al., 2018; Ocloo & Matthews, 2016).

At an unconscious level, during meetings with a CAB, investigators often split off their own dependency needs in an effort to maintain their power and control over the research process (Brown et al., 2020). This often means refusing to include Veterans in meaningful ways, such as permitting Veterans to make project decisions that count, while restricting engagement to answer-seeking. The result is a one-sided conversation that limits a CAB's authority over and knowledge of research (Brown et al., 2020; Ocloo & Matthews, 2016). This scenario is where an awareness of group dynamics and how this intersects with dependency needs can have a real impact on both the investigators and the CAB.

At VA, the electronic medical record makes a huge cache of longitudinal health data available to researchers, who routinely mine this data (Abel et al., 2016; Rein, 2022.). This data is made possible by the trust and willingness of patients to contribute to the data set: through informed consent, veterans enable the data to be collected from their patient visits. Were investigators to behave in ways that demonstrate consciousness of their anxieties and split-off dependency needs, they could use their power to initiate formal steps that would ensure Veterans know that sharing their health data serves their interests. Reporting the results of their studies back to every Veteran collaborator would build greater trust in the research relationship, enabling a Veteran to understand how their data is used, and whether the research is relevant to their care (Clark et al., 2019). However, researchers infrequently report back to Veterans outcomes from their work, avoiding questions from Veterans, and discounting their agency. On the surface, the motive behind these paternalistic behaviors appears to be a desire to protect Veterans from the information they may not entirely understand, or from anxiety or worry about their health conditions (Melvin et al., 2020). However, this splitting allows researchers to maintain power and control over the research process, and ends up fostering Veteran ignorance, mistrust and submissiveness; the Veteran is disempowered, reinforcing an unequal relationship (Hahn et al., 2017; Ocloo & Matthews, 2016; Pinto et al., 2013).

The CAB carries other hidden and obscured values, as well. These are typically unexamined values and expectations that appear designed to make researchers comfortable. PIs often have an extensive home court advantage (Brown et al., 2020) that may influence the expectations with which they approach a CAB. First among these, the CAB will present to PIs new ideas and suggestions to change or improve healthcare delivery in ways that will not be a burden for the system to implement (Oshry, 1995/1996, 1999). These unchallenging suggestions will likely enable the institution to remain within the status quo. In addition, these offerings should mean that CAB proposals will be readily accommodated by an institution. This gentle framing ensures that a CAB does not present a challenge to the researcher’s institutional power and authority.

Very often, PIs believe that they are in equal relationships with their patients and research subjects when, in fact, they are unconscious of stark power differences (Young et al., 2019). PIs would benefit from awareness of their greater institutional power and the ways they are able to wield it. For example, there is the expectation among PIs that, rather than angry outbursts, the CAB will behave in ways researchers find easy to deal with. Questioning researchers about a proposed research focus should be a polite conversation, avoiding disagreement or mention of difficult topics such as racism, structural sexism, and similar. When problematic issues are raised, PIs have the option to engage but, if discomfited, may defend themselves by stating concerns like these, an inherent component of seeking care for marginalized and minoritized groups, are not their expertise. Thereby PIs may use their greater power to end the conversation. When CABs meet with researchers, positive outcomes may hinge on whether Veterans and PIs see themselves as equals with equal status in the VA, with both sides able to raise issues that are of concern, bearing in mind that even a difficult conversation may ultimately be rewarding.

We will now turn to specific examples of CAB interactions with researchers that are more difficult to confront and decipher. This is where our multi-valent framework will be most useful in our estimation. Veterans are an extremely diverse group, representing every major social group in the United States, diversity that is believed to be very valuable, often because what works for Veterans will also work for the country as a whole, medically speaking (Asch et al., 2010). At times, the CAB's task is to represent the military, the minority group, or the gender groups to which they belong. However, most of the time, CABs are asked to generalize about the views of Veterans, the majority of whom are white, male, and able bodied, in ways that are race-, sex-and gender-blind (Population Page 2022). Therefore, CABs at VA are asked by researchers to either directly and/or indirectly place themselves into the mindsets of multiple social groups.

CABs like ours are particularly important for representing the views of vulnerable and minoritized groups that are predisposed to multiple inequities and disparities when seeking healthcare (Saha et al., 2008; Walsh et al., 2015). When a researcher minimizes the intersectionality of Veterans—that is, the simultaneous and multiple layering of Veteran identities and statuses in relationship to structures of power— in favor of the dominant group, the interaction with the CAB centers answer-seeking from the frame of the white male Veteran (Heard et al., 2020; Rosette et al., 2008). This masks positionalities that influence the Veterans’ health. An example of the container and contained, in this interaction, CAB members are asked to “carry” or personify a social group without falling prey to the stereotypes of that social group. This framing fails to name the dominant group of Veterans while still covertly eliciting their views, suppressing individual Veteran racial, sexual, ethnic, or other identity. At times, the CAB contains organizational prejudice, bias, suppression of points of view, and contradictions in values, in service of developmentally appropriate growth for VA (Billow, 2000; Petriglieri & Petriglieri, 2020). Equally, the CAB will need to contain investigator prejudice, arrogance, superiority, and displays of status with equanimity. Rather than succumbing to frustration and anxiety about not being asked about the views and experiences of their specific social group, the CAB must be willing to moderate their views, though this may be an additional burden. Moreover, in terms of parallel process, where the CAB mirrors the institutional concerns and conflicts, this interaction mimics VA's institutional deficiency and inadequacy, disregarding the lived experience and intersectionality of, for instance, Veterans of color and/or women Veterans when providing care (Betancourt et al., 2021; Bloom, 2010; Hausmann et al., 2020; Smith & Zane, 1999; Smith et al., 1989; Sullivan, 2002).

The inequities and disparities among Veterans that trace their roots to racism, sexism, xenophobia, and homophobia VA and its researchers find very difficult to address openly, such as sexual harassment among patients, and patient and employee experiences of racism (Cannedy et al., 2022; Mitchell, 2020). Importantly, because a CAB may be willing to discuss these concerns, inequality and disparity are now in the custody of that CAB, where it must contain the mixture of feelings about VA alongside the organization's anxieties and contradictions that result in health disparities. However, most researchers do not ask Veterans about inequities they confront at VA if it is not their specialization (Chaiyachati et al., 2022). Accordingly, because these adverse experiences remain widely unacknowledged, they are further likely to undermine the CAB.

Whatever subject the CAB brings up ought to be discussable (Argyris, 1980). However, this is not always the case. For instance, if a VA researcher asks a CAB to pinpoint directly how a policy overlooks the needs of persons of color or gender minorities, VA research as an institution may react negatively. For example, Veteran homelessness had been a known problem since Reconstruction (Tsai, 2018), but VA did not prioritize ending Veteran homelessness until 2009, meaning that VA was successful in splitting off and projecting a serious problem revealed by its own research. The criticisms of this policy itself may not be the issue, but the explicit manner in which the policy failures are exposed may shut down the conversation. The harm of VA's failures to address housing among Veterans was further exposed in qualitative research into Veteran homelessness published beginning in 2012 (Hamilton et al., 2012; Thompson & Bridier, 2013; Tsai & Rosenheck, 2013). This research highlighted the way in which homelessness disproportionately affects aging Veterans, women Veterans and Veterans of color. Decades of research did not present the problem in such a way that compelled VA to act. Qualitative work--the direct report of Veteran lived experiences in their communities--seems to have catalyzed VA's change in policy. What was different about this episode is that Veterans’ direct engagement in research meant that VA was unable to minimize the issue as it had done in the past. The negative exposure of VA's internal contradictions precipitated substantial resources directed at the problem.

If the failures are unconscious by the institution, a defensive backlash as we saw above will likely be disempowering to a CAB, especially if the members carry a situation the larger organization finds uncomfortable, (e.g., women Veteran CAB members experiencing sexual harassment on VA grounds, Cannedy et al., 2022). Such embodiment makes a CAB vulnerable to tokenism: The extent to which the organization displays discomfort with what the CAB is carrying is the extent to which it will feign attention, emphasizing the CAB's otherness. On the one hand, as a CAB puts forwards useful ideas and inputs, though the organization may delay action until some problems raised by the CAB can no longer be ignored, the organization will praise and bestow greater institutional power on the CAB. On the other hand, when the CAB surfaces dissonance between a formal consultation and covert features of the institution, this conduct may create harmful disruption of organizational relationships that support the CAB's functioning. Therefore, what the CAB is carrying on behalf of the institution may engender the very disruptions it was designed to prevent.

Being inside VA, Veteran CABs are often caught in the middle between powerful opposing forces. The CAB must express and harbor individual feelings and frustrations of Veterans not satisfied with their care, while consciously disentangling these feelings from their behavior as advocates. Indeed, engaging with CABs provides a buffer to Veteran complaints of not feeling heard. The CABs very existence is an acknowledgement that VA research attachment to the community it is designed to serve is poor and that Veteran CABs exist as advocates. Moreover, if the CAB criticizes VA too vociferously, they may become adversarial and lose their ability to influence VA research. Yet the CAB is also inside VA and must avoid falling prey to being detached from the wider Veteran community. The CAB's unacknowledged position is constant tension: They must contain the feelings of being an outsider without actually becoming an outsider. CABs also carry the ideal that VA research is doing its utmost to improve Veteran health, but also the covert unspoken expectation that, like a family member, CABs will defend VA research from criticism, as in our identified patient family dynamic above. In truth, the CAB provides cover for widely acknowledged weaknesses in VA care that research has not adequately addressed (Saha et al., 2008).

If during their dialogue with researchers a CAB points out that a policy is injurious to a disadvantaged Veteran subgroup, researchers may find the CAB's criticisms disorienting. Because inequities and inequality are powerful components of the healthcare delivered by VA (Saha et al., 2008), and because, to the members of the CAB, researchers are representative of and have power in the delivery system, once the CAB points out inequity or intersectionality, researchers may become uncomfortable with their status (DiAngelo, 2011). Researchers are typically unwilling to carry or contain VA's disparities and inequities, though they are willing to report on them, splitting off and projecting their advocacy responsibility onto a CAB (Chaiyachati et al., 2022).

Periodically, a CAB will rebel against this tremendous responsibility of carrying and raising troubling features of an institution, especially if the responsibilities, values, and expectations surrounding those features remain disowned and unspoken (Brown et al., 2020). Further, as we have seen in our prior work, when expectations, autonomy, authority, and boundaries are unclear, expressions of futility are likely to result (Brown et al., 2020). If a CAB is surfacing dissonant expectations and values in their meetings, then it is imperative that the expectations surrounding the work of the CAB be revisited. All the components of the organization invested in the CABs work must contribute to this revised set of expectations.

When a CAB demonstrates a practical understanding of informal and hidden expectations, they are then in a position to transform them into formal expectations and do something about what they uncover. Hence, the group must possess the awareness, autonomy, and strength to contain organizational biases. The organization may suppress diverse or unpopular points of view, defer action on pressing issues, and display contradictions in values, all of which the CAB must resist in the service of growth for the organization. As a result, the CAB carries expectations, values, and responsibilities for the system that will allow the institution to actualize its aspirations, acknowledge its hidden issues, surface its conflicts in values, and grow developmentally (Billow, 2000). In cases like these, CABs are providing a containing function as they carry these issues for the department or system. Accordingly, a potential downside is that the CAB must mediate these expectations, values, and responsibilities, listening and engaging with all parts of an institution, without falling prey to hardened views about the institution. If the CAB does fall prey, it may display or experience dysfunction and/or feelings of futility especially if it is unable or unwilling to contain or carry hidden aspirations, issues, and conflicts.

Discussion

Here, we will briefly describe how these carrying functions manifest at our Center and how we respond to them. From the very beginning, the Veterans in our CAB articulated tensions and aspirations that were latent in our Center's health equity research. Organizations tend to respond to tensions by attempting too quickly to resolve them rather than exploring and containing the tensions (Diamond, 1998; Riesenberg-Malcolm, 2009; Rosenbaum & Garfield, 1996; Smith & Berg, 1987). The CAB forced our Center to confront issues to which it had not given much thought until the Veterans surfaced them: investigators appearing untrustworthy; transparency about what the organization gains from Veteran participation, and the amount of time it takes for Veteran-researcher collaboration to bear fruit. Information learned from the Veterans, especially in the area of health disparities, had to be acted upon. This is the most difficult issue that our Center confronts.

Formally, the carrying function for our CAB has centered around questions of power and agency. To instill in the members a formal sense of their position and power at the VA, we gave them official federal appointments and incentives. The informal part was to groom them to talk to researchers like they are colleagues engaging in dinner conversations around complex issues.

The hidden aspects of power that the CAB carries have more serious ramifications. What CABs carry for the institution, when acknowledged, can become springboards to greater trust, respect, productivity, and achievement. Meaningful Veteran engagement in research requires that power be balanced between the Veterans and the researchers. Unfortunately, bi-directional communication that reflects that balance has been difficult to establish owing to the time it takes to build trust and to create consistent positive partnerships and equitable power dynamics (Lucero et al., 2016; Safo et al., 2016). Most studies at our Center remain at the consult level (CATSAC et al., 2011). In what could be considered threatening to PI authority, it has been rare to even consider “Collaboration” and/or “Shared Leadership.”

Our CAB represents voices of Veterans who, at times, endure mistreatment in their healthcare, and who are distrustful of VA and the care they have received (Jones et al., 2021). Further, Veterans of color, like many Black Americans, are often skeptical of research, stating emphatically that academic medicine's past deceptive experimentation taints their current views (Melvin et al., 2020). Our Center must remain an open and consistent bridge empowering Veterans to speak about their VA experience and to act on those experiences by including and/or acknowledging them in our research designs. We must also freely admit to our efforts to establish trust, an essential factor in effective Veteran community engagement. However, trust building may be a difficult undertaking, as it is not always possible to insert Veteran observations and suggestions into a research program, though this would be a clear way to help a CAB feel heard and an obvious way to increase trust (Lucero et al., 2016).

The ways that Veterans are engaged directly in research—focus groups, interviews, consensus panels—are validated methods, but they are not designed to empower participants to make meaningful decisions or to be an authentic advocate (Foth et al., 2016; Subica & Brown, 2020). In these settings, the carrying function plays out in different ways. Formally, CABs may realize the value of the validated methods. Informally, they may question how the method will gather accurate data. But unacknowledged is whether Veterans feel empowered to convey their true feelings through the PI's chosen data-gathering strategy (Foth et al., 2016). A CAB carries the relentless struggle to be heard and to be authentic, especially those voices of the most vulnerable and marginalized Veterans. Meaningful engagement is a challenge to PI authority and a contributor to the reluctance to have Veterans as co-investigators, collaborators, or shared leaders on research projects (Lucero et al., 2016; Safo et al., 2016). Accordingly, institutions like VA want Veteran CABs to be community members and not researchers—their role is in fact to be something in between, or at times, a bit of both.

At our Center, as we explained above, the CAB carries PIs’ splitting and projection that they are not dependent on Veterans for research data. As a result, in engaging CABs in medical research, we are asking CABs to perform a significant amount of emotional labor (Grandey & Gabriel, 2015), at times acknowledged and at other times not. In this way, CABs must carry the anxiety, conflicts, and discomfort of our Center's researchers, that their work may exacerbate existing disparities for Veterans. Meanwhile, the Veteran CAB must continually advocate for marginalized and underserved Veterans when confronted with the researchers’ fears and worries. The splitting results in the PIs projecting their unwanted dependency onto the members of the CAB (Bennis & Shephard, 1974/1986). If CAB members are not conscious of the tensions of this role, they are likely to exude frustration with researchers. Therefore, CABs require support to navigate their formal role and their feelings about it without falling victim to their feelings, a classic example of the containing function.

Moreover, even if a CAB offers suggestions to improve the research or system, the researcher may not follow them. There is no penalty for the researchers’ dismissal of the CAB's advice, but there is a penalty for the CAB. The CAB may blame itself for not adequately advocating for the needs of its community and may fall prey to fearing the community they serve, owing to a loss of authority.

Veteran engagement at VA is in its infancy. VA is not yet culturally competent or culturally safe to parse the voices of the subgroups that it must serve (Brommelsiek et al., 2018). Importantly, the most burdensome unacknowledged expectation that CABs at VA must embody to researchers is the voice of the average white male Veteran, even if a CAB member is not of that group. The Veteran community is 89% male, and 73% white (Population Page, 2022); therefore, by speaking for this dominant group, a CAB protects VA from claims of sexism, racism, etc. by also personifying and voicing the experiences of, when possible, underserved groups afflicted by these social ills. By unspoken or unacknowledged we do not intend to imply that there was anything wrong or bad about the expectations, but that they were obscured and thus more difficult to receive, perceive and interpret. As we have seen with the identified patient literature that we examined above, this carrying a CAB for the larger organization and its attendant emotional labor is an underappreciated aspect of CAB functioning that can possibly enhance or disrupt its effectiveness. If the CAB is carrying some unexamined components of the organization's functioning, this can result in the CAB becoming tokenized (Brown et al., 2020; Hahn et al., 2017; Ocloo & Matthews, 2016).

What to do when these difficult, even pernicious, features of group life become apparent? The expectations with which the CAB operates must be revisited by both the CAB and its organization (Brown et al., 2020). The authors are faculty members of the Center and who possess knowledge of advanced group dynamics and superior facilitation skills. Accordingly, we believe that an experienced facilitator would be needed to guide the revisiting process and its attendant conversations. If difficult dynamics regarding identified patient processes arise, it is important for CAB facilitators to highlight and make conscious of the familial relationships being reenacted between the group and the organization, rather than scapegoating or making heroic the group. These discussions will enable the CAB to make a meaningful choice whether to take on these qualities as a part of their role, a true form of empowerment. Similarly, to deal with the negative consequences of splitting and projection, those dynamics need to be made conscious to the group as well. Rather than falling into the trap of taking on splitting and projection, this awareness will enable the group to perform proactively and with confidence in its interactions with the organization.

Groups mirror their organizations. However, to prevent the CAB from mirroring system inadequacies, enable the CAB to design processes that reflect their own needs, but that also resemble the way the organization handles similar needs. For example, to devise solutions to specific problems, the CAB may create subcommittees and work groups in much the same way an organization creates a task force.

A remedy regarding problems with containers and contained may be to set a series of agreements for every meeting (Bens, 2016). These agreements would highlight likelihoods such as the fact that uncomfortable or anxiety-producing subjects may be discussed (racism, microaggressions, etc.) alongside issues that are less provocative. This procedure can be instituted at the start of a meeting by CAB leaders or facilitators and will help to create an atmosphere where difficult matters can be discussed without fear of judgment and communication breakdowns. A useful set of meeting agreements might list appropriate behaviors for the meetings, such as being ready to voice reactions and ideas, and actively listening to others, exhorting participants to treat all with dignity and respect and to view conflict as an opportunity to understand differences.

These informal and unacknowledged expectations above must be discussed, integrated, and formalized into the CAB's foundational operating functions. This effort might be engaged by hosting a retreat or similar discussion format where the CAB can surface the tensions surrounding changing expectations. This meeting needs to bring to light what has changed, how this affects the relationship between the CAB and the organization, and envision the future support needs of the CAB which the organization must provide. When CABs are attuned to their organization, they have the information they need to do their work, they feel coordinated and supported, and they are able to adjust their performance to the needs of the system. The CAB's members feel in sync with, and supported by one another, they feel significant within the system, and they feel powerful and independent (Oshry, 1995/1996).

There have been some surprises along the way. Our CAB has displayed an extraordinary level of creativity and innovation, addressing gaps in the processes that surround Veterans’ participation in research. Owing to the authority and independence bestowed on our CAB by our Center, they have freely offered enhancements and executed improvements that have been embraced by our research community. From recommendations surrounding compensation to trauma-informed approaches to recruitment, their contribution to enhancing the Veteran experience of research has been unquestionably positive. This creativity and innovation are mirroring our wider VA's embrace of inventive advancement in medical practice, which is a type of parallel process. Additionally, our CAB is rather bureaucratic, instituting multiple processes to gather information, which also mirrors VA. Our CAB has introduced forms and requests for information and has engineered a committee framework that resembles the structures of our agency and of the military. Notably, these activities are not elements of what they were formally chartered to achieve. These enhancements of the research enterprise are all informal expressions of CAB power and autonomy. Furthermore, these are the efforts that have raised the visibility of the CAB. In a virtuous cycle, as their visibility for these informal achievements increases, so does their perceived authority and competency. What starts informally and with good results may need to be transitioned into the formal role of the CAB with respect to the organization. Expectations surrounding this changing role and status must be managed. Therefore, expectations may need to be periodically revisited, especially the informal functions the CAB is carrying.

Conclusion

CABs provide a healthy and protective way for Veterans to talk about–carry—a range of feelings: their gratitude, displeasure, vulnerability, and even hostility toward needing care and receiving it at VA. Engaging Veterans this way also provides for those feelings to be contained. Understanding these psychodynamics help sustain Veteran CAB effectiveness and enable expectations, values, and difficult conversations to be acknowledged and embraced. We have shown here the ways in which formal, informal, and unacknowledged values, expectations, and responsibilities may become pivot points to support institutional goals or to entrench disowned organizational deficiencies. Members of our CAB are keenly aware they advocate for positive health outcomes on behalf of all Veterans, a way of thinking about their role based on their collective experience.