Quantum candies (qandies) represent a type of pedagogical simple model that describes many concepts from quantum information processing (QIP) intuitively without the need to understand or make use of superpositions and without the need of using complex algebra. One of the topics in quantum cryptography that has gained research attention in recent years is quantum digital signatures (QDS), which involve protocols to securely sign classical bits using quantum methods. In this paper, we show how the “qandy model” can be used to describe three QDS protocols in order to provide an important and potentially practical example of the power of “superpositionless” quantum information processing for individuals without background knowledge in the field. Quantum information processing (QIP) has been an intensively studied field in the academia ever since Feynman originally proposed the idea of quantum computing in 1982 [Currently, one of the most prominent research directions in QIP  is the topic of quantum digital signatures (QDS). Before we discuss QDS, we briefly mention the historical background and motivation to QDS-classical digital signatures. The idea of digital signatures was first proposed by Diffie and Hellman  in 1976.Since then, many classical digital signature schemes have been proposed, including the famous Lamport’s one-time digital signature scheme  which w. The maiIn 2001, Gottesman and Chuang  first prSince Gottesman and Chuang’s work, much research has been done in attempts to overcome said shortcomings. In 2006, Andersson, Curty, and Jex  came up Most relevant for our work, in , WalldenAlthough quantum information processing has gained a great deal of popularity, understanding its fundamental rules requires familiarity with non-trivial concepts from physics and mathematics, such as superpositions, unitary transforms, and complex linear algebra in general. In an attempt to improve accessibility to this important field of science, an idea for a simplified model was first proposed by Jacobs—the “Quantum Candy” model. The model was later greatly expanded and defined in ,13.In essence, the “Qandy Model” abandons the notion of quantum bits (qubits) in favor of “Quantum Candies” (qandies)—mystical candies that, similarly to classical bits, only have a discrete set of possible states, but unlike classical bits do behave essentially “quantumly”. It is shown and discussed in ,13, thatcannot be implemented using the qandy model , the qalgorithm , certainIn this paper, our goal is to present quantum digital signature protocols with QKD components, relying on ,10, usinIn We begin this section by introducing the goals of Digital Signatures (DS) schemes, their usages today and present a definition. We then shortly describe the Lamport’s signature scheme —a simpleM to the recipient Bob. Is there a way for Bob to ensure that Alice is indeed the sender of M? In other words, can Bob find a way to ensure that a malicious third party, Eve, was not the one sending M in the name of Alice, or did not tamper with its content?Let us examine the following scenario: a sender, Alice, sends the message unforgeability.This type of scenario happens frequently in our era of digital communications. For example, during credit card transactions, a bank obtaining a request from one of its clients to transfer money to another account and needs to make sure the request was indeed made by the client. We call this desired property M (and signed it) and later on denies that she is the one who signed it? Namely, she claims someone forged her message. In this case, Alice is the dishonest party, and we would like to prevent her from successfully executing such trickery. A digital signature scheme preventing this behavior is said to promise non-repudiation.What happens if Alice made a future promise to Bob through a message transferability. Transferability is closely related to the second property of non-repudiation, and many times these two properties are identical; for example, when a dispute is settled by majority decision. One can also think of bad schemes when the two are not entirely equivalent, for example, when transferability is not promised even when Alice is honest.Lastly, a good digital signature scheme should promise a recipient who accepted a signature that any other recipient would accept it as well. This property is called The classical digital signature scheme has a conventional, formal definition , which We present a version of the Lamport scheme for one-bit messages. We also repeat this explanation in a formal way and using formal definitions in Let Alice be the sender of a message Private key generation For each value of Public key distribution For each value of b, Alice calculates and publicly announces Signed messaging If Alice wishes to send Bob a signed one-bit message m, she sends m is Verification When receiving H and Arbitration A dispute occurs when Bob claims Alice sent a message m, and Alice denies it. If Bob is dishonest, this is the forgery attempt case. If Alice is dishonest, this is the repudiation attempt case. A dispute is settled in the following way: Bob sends Charlie the value of Unforgeability is guaranteed since, if H is a one-way function, Bob will not be able to find such Non-repudiation is guaranteed for the same reason: if Bob managed to present such One-time pad (OTP) is the popular name for the one-time pad cipher also known as the Vernam cipher or the Vernam code. There is some ambiguity regarding those terms, and thus we clarify here precisely what we mean: Vernam cipher or OTP cipher is the use of a random string of bits pre-shared by a sender Alice and a receiver Bob, named the “pad”, to send secret strings , by using the bit-wise XOR operation between bits of the pad and bits of the secret message. It is crucial for the security of the transmitted secret that the pad is only used once—hence the term one-time pad.We refer here to the random and pre-shared pad as the OTP, and we present a signature algorithm invented by WDKA , which wThe OTP-S of  is not tAs before, we assume three parties, Alice, Bob and Charlie, and arbitration is required if Bob provides a document (one bit in our case) claiming it is signed by Alice, and Alice said she did not sign this document. We assume that in this protocol  the arbiter Charlie is always honest.Let us assume that each pair of users share in advance random strings  of any desired length, and that each secret random bit is used just once; hence, it is a one-time pad. However, it is not a one-time pad cipher.We note that a small number of bits from the pre-shared secret strings can be used for authentication via universal hash functions ,20. ThusPrivate Key Generation For each future message bit “Public” Key Distribution For each future message bit “Public” Key Symmetrization For each future message bit Signed Messaging For signing a specific bit Verification Bob accepts Alice’s signature if it matches his key Arbitration In case of a future dispute regarding the message content, Bob forwards to Charlie the string (a)There is no mismatch between Bob’s forwarded (b)The number of mismatches between Bob’s forwarded Charlie accepting means he accepts Bob’s forwarded message as valid, i.e., Alice is the dishonest party, and a rejection means Bob’s forwarded message is invalid, i.e., Bob is the dishonest party.We now outline the classical protocol; it is nearly precisely P2 of The protocol is proved to be secure against repudiation and forgery for a choice of found in . IntuitiWe shall repeat similar steps when discussing P2 in We now present the notion of quantum candies (or qandies) as presented in ,13. The qubits, or quantum bits. To create a qubit, one uses a physical system with quantum properties, such as the polarization of photons, and maps the state of the system to a qubit value. This is similar to the classical case, when (for example) a presence of current is mapped to the bit “1”, and absence of current is mapped to the bit “0”. However, due to the laws of quantum mechanics, qubits present extraordinary properties that are very different from the classical world.However, in the world of quantum communication, there are transmissions of Those properties have significant information-theoretic consequences , and the notion of quantum candies helps explaining some of those properties in a simple and mathematics free manner ,13. In tImagine two parties, Alice and Bob, who wish to communicate with each other. For simplicity, let Alice be the sender of a message and Bob be the recipient.one property out of the following options: Green color R, G, C, V, which match the properties, respectively.We equip Alice with a machine that can generate a special kind of candies, called “qandies”. At any given time, each qandy has exactly V} button and Bob decided to taste the qandy, then he will taste vanilla. Similarly, if Alice prepared a qandy with a certain color, Bob can look at the qandy and he will see that color, e.g., if Alice pressed the {G} button and Bob decided to look at the qandy, then he will see a green qandy.When receiving a qandy, Bob can either taste it or look at it (but not both at the same time): if Alice prepared a qandy with a certain taste, Bob can taste the qandy, and he will measure that taste, e.g., if Alice pressed the {This way Alice can send the qandies to Bob, with one color mapped to the value “0” and the other to the value “1”. Similarly, one taste is mapped to “0” and the other to “1”.V} button and Bob decided to look at the candy’s color? This scenario is what makes Alice’s qandies so special, and gives them their quantum-like properties that turn them into “qandies”. If Alice prepared a certain property (taste or color) and Bob decided to measure the other property, then he will measure a random outcome (out of the two possibilities for the measured property). Thus, if Alice pressed the {V} button and Bob decided to look at the qandy’s color, he will see Red with probability of What happens if Alice pressed the {This means that only the original property prepared by Alice is meaningful, since measuring the other property leads to a completely random outcome. To quote the original paper ,13: “TheIn particular, as also shown previously in  and evenb, based on the P1 QDS protocol of [We now describe a digital signature protocol using quantum qandies. The protocol is a one-time signature protocol for signing a single bit tocol of . The proAlice is in possession of standard qandy generation capabilities: she can create qandies of the four types lossless but potentially insecure “qandy channel”, namely: for each qandy sent by a sender, some qandy is received by the receiver .Between each two parties, there exists a Bob and Charlie possess standard qandy measurement capabilities: they can either look at or taste the qandies.Bob and Charlie possess a “qandy memory” capability, namely they can store received qandies indefinitely and measure them later.Between each two parties there exists an authenticated classical channel ; no eavesdropper or noise can change the classical bits sent between the parties.The assumption in Item 4 is not strictly necessary . The key length n is the security parameter of the protocol.“Public” Key Distribution For each future message bit two copies of qandy strings (“public keys”) “Public” Key Symmetrization For each future message bit (a)Bob (Charlie) decides on a random subset of (b)Bob (Charlie) randomly looks at or tastes each of the (c)Alice discloses part of the qandies to Bob and Charlie , for TEST. There are two TESTs:i.Between Alice and Charlie, in order to make sure Bob did not attempt to eavesdrop in Step 2 (distribution).ii.Between Alice and Bob, in order to make sure Alice did not attempt to eavesdrop in Step 3 (symmetrization).In both TESTs, both parties choose which indices they want to reveal.n), such that the probability of a noise rate higher than Bob and Charlie abort the protocol if the noise rate Both TESTs have to be done with Alice’s participation, because only Alice knows the true values of the qandies she sent and may reveal them to Bob and Charlie as necessary.In the TESTs, qandies with conjugate measurement bases  are removed from the statistics and do not contribute towards the noise rate calculation.At this stage, Bob and Charlie do not yet know the indices of the qandies that were received from the other and were not TEST qandies.Signed Messaging For signing a specific bit Verification At this stage, Bob and Charlie disclose to one another all the indices of the qandies they forwarded in Step 3, via an authenticated classical channel. Bob counts the number of mismatched indices between his measurement results of i occurs when Alice’s private key character G. On the other hand, if C, then this is not a contradiction as he chose the wrong basis.A mismatch for index Bob accepts Alice’s signature if the number of mismatches is smaller than Arbitration In case of a future dispute regarding the message content, Bob forwards to Charlie the string Following are several remarks on the protocol.In Step 2, the requirement to create two copies of the qandy strings stems from the no-cloning theorem for qandies ,13: Bob each qandy obtained from Alice whether to measure it or forward it with equal probabilities. The protocol is then aborted if each of them received from the other a number of qandies too far from In Step 3, the fact Bob and Charlie have a “qandy memory” allows them to select a random subset of tocol of  Bob and n, after the exchange Bob and Charlie will each have zero copies of i with zero copies, they cannot eliminate any possible value of the private key and hence have to accept any claim by Alice for that index. On the other hand, for an index i with two copies, they can eliminate at most two possible values of the private key—by looking at the first copy and tasting the second.In Step 3, Bob and Charlie do not exchange the same random subset of qandies, since the choice is made by each of them independently. For large Security of a digital signature protocol relies on non-forgery (by Bob) and non-repudiation (by Alice). In the following section, we provide a basic intuition for the qandy signature protocol being secure against forgery and repudiation, based on the full analysis of  done forFor a successful forgery, a cheating Bob has to guess a signature surement  on his cn.Overall, it is shown by  that, foFor a successful repudiation, a cheating Alice has to cause Bob to accept her signature in Step 5 (verification) while Charlie rejects it in Step 6 (arbitration). Even if Alice sends different public keys It is shown in  that AliWe assumed the “qandy channel” employed by the participants is noisy, either due to natural noise or eavesdropper activity, with probability smaller than be shown  that havFollowing , with thIn order to minimize the probability of any “bad event”  happening, the parameters Equation  is equalGiven the original constraint of requiring authenticated quantum channels in P1 of , an alteIn this section, we first discuss the P2 protocol and compare it to P1 and then discuss ’s and coAs we already clarified, the protocol P2 is, in a sense, a “classical” signature scheme, based on shared secret classical keys. The secret classical keys in P2 are obtained using QKD techniques, and thus the protocol may be implemented using qandies, by applying qandy QKD as described in ,13. The We now provide several remarks on the protocol and compare it to P1:classical public keys instead of quantum/qandy keys, and only the method to obtain those keys is quantum/qandy based .Our main idea in the current paper was to use the qandy model to present a simplified version of the P1 quantum digital signature protocol presented by . Then, wThe work is meant to serve mostly as a continuation to the ideas presented in ,13, withWe end by proposing several potential future research directions with respect to digital signatures with the qandy model. First, in


It argues that the Lacanian concept of trauma offers a timely antidote to dominant psychiatric notions of trauma today, linked as they are to the questionable politics of ‘Post-Traumatic Stress Disorder’ and, more recently, of ‘Post-Traumatic Growth.’This article makes the case for the largely unacknowledged relevance of the thought of the French psychoanalyst, Jacques Lacan, for the emerging field of the medical and/or health humanities. From the 1930s all the way through to the late 1970s, Lacan was deeply concerned with the ethical and political consequences of then-dominant conceptions of the human in the ‘psy’ disciplines. His attempt to ‘humanise’ these disciplines involved an emphasis on humans as  Diagnostic and Statistical Manual which creates an entirely new class of ‘Trauma and Stressor-Related Disorders’ (American Psychiatric Association 2013). The DSM-V also implies the transmissibility of trauma beyond direct personal experience of it: one can now be traumatised by witnessing or even hearing of the traumas suffered by others.The term trauma has become something of a cultural lightning rod since the mid-twentieth century, attracting enormous attention in the fields of cultural and social theory as well as psychology and psychiatry. We have seen the rise of the discipline of Trauma Studies which touches on everything from the Holocaust to Rwanda, from the Truth and Reconciliation Commission in South Africa to post-9/11 . Regarding the psy disciplines (Rose 1998), we have seen early acknowledgements of traumatic memory, links between shell-shock and the so-called ‘war neuroses,’ and more recently the recognition of ‘Vietnam Syndrome’ and then ‘Post-Traumatic Stress Disorder’ (PTSD). Like addiction (Wright 2015), the scope of PTSD has expanded considerably in the latest edition of the victim, to the victim’s rights in a compensation culture, and ultimately to the geopolitics of human rights. Within the positive psychology movement led by Martin Seligman, PTSD has also been inverted into Post Traumatic Growth (Seligman 2011), arguably a psychological equivalent of the neoliberal principle that ‘every crisis is an opportunity’ in disguise (Mirowski 2013). Nonetheless, it remains talk in a technical sense: one must learn the language of trauma, whether through the DSM’s vocabulary of ‘intrusion,’ ‘avoidance’ and ‘hyper-arousal’ or through an engagement with self-help literature with its language of ‘survivors’ and ‘recovery.’ In the field of critical social theory, there has been an ethical discourse around the notion of trauma ever since Adorno declared the impossibility of poetry after Auschwitz (1990). By contrast, in today’s more diffuse and medicalised ‘trauma talk,’ there is a loquaciousness that deserves to be characterised as a ‘discourse’ in Michel Foucault’s specific sense (1980). The discourse of trauma talk in fact abhors silence, insisting that trauma must be verbalised.Trauma talk involves invoking the charged signifier ‘trauma’ in ways that have concrete consequences in the world precisely thanks to the absence of a consistent referent. Such trauma talk circulates fairly easily, not because of its conceptual rigour or correspondence to an empirical reality necessarily but because it catalyses sets of values and practices that I want to argue perform operations of individuation relevant to broader neoliberal agendas. Trauma is linked, after all, to the figure of the which Freud? There are many after all. Which one does ‘trauma talk’ invoke? Speaking very generally, it seems to be the Freud of the very early Seduction Theory which can be dated back to a paper delivered in April 1896, entitled ‘The Aetiology of Hysteria’ . What Freud outlined in these so-called Seduction papers is indeed a post-traumatic model of neurosis, but one which, crucially, is not psychoanalytic.For better or for worse, behind the success of ‘trauma talk’ is undoubtedly a certain reading of Freud. For Trauma Studies as a cultural and social theory, Freud is still credited with recognising the link between trauma and repressed or screen memories and also with trauma’s resistance to psychic representation at the individual and social level . Even the psychiatric framing of PTSD retains a clear indebtedness to Freudian ideas about repression and repetition compulsion. But as a psychoanalyst, I have learned to always ask memory: these women, he believed, had suffered actual experiences of sexual abuse, but the resulting memory traces had been repressed from consciousness. Finding no psychic representation in the memory system, this traumatic imposition from the outside, of a sexuality for which these subjects were not developmentally ready, was both repressed and expressed in their conversion symptoms, as if their bodies spoke of what their minds could not confront. The classic example among Freud’s case studies is ‘Emma,’ a young woman who presented with a phobia of entering shops. During analysis, she was able to access a repressed memory from her eighth year when she was molested by a shopkeeper. Most of the elements of trauma as now popularly conceived are already present in this Freudian example:a terrible shock ‘hits’ the organism from outside;this shock is linked to either the threat of death or imposed sexuality;it cannot be processed through existing frameworks of meaning;yet the repressed returns in repetitive symptomatic forms .Freud’s Seduction Theory arose from his early clinical work with hysterics in collaboration with Josef Breuer (Freud and Breuer 1991). Because free association seemed to reverse the repression of erotically charged material, Freud postulated an aetiology for hysteria based on a model of traumatic As well as establishing these foundational elements, Freud lent impetus to the notion that the very act of talking about a trauma can potentially cure it. This fits well with today’s therapeutic culture which has commodified this aspect of Freud to the point that the company British Telecom could turn it into a marketing slogan in the 1980s—‘it’s good to talk.’ But what is forgotten here is the peculiar specificity of talking in analysis under conditions of transference and free association, very unlike everyday communication. Clinically speaking, it is certainly not the case that it is always ‘good to talk’ too quickly or too directly about a trauma. What is also forgotten is that Freud utterly renounced his Seduction Theory and had to, in order go on and invent psychoanalysis proper.not always relate to repressed memories of real events. He was moving away from the restrictive model of experiential memory in order to better describe an unconscious he increasingly realised observed distinct laws. He therefore came to postulate that the sexual nature of these hysterical ‘memories’ related not to real experiences per se but instead to Oedipal fantasies and to the constitutively libidinal nature of the unconscious itself. For good reasons, this move has been a controversial one (Masson 1992), but only by abandoning the early Seduction Theory could Freud make the truly revolutionary arguments he developed in his Three Essays on Sexuality (1977). Whereas the pre-psychoanalytic Seduction Theory presented the trauma of sexuality as an external contingency, shocking the psychic system from without, the libidinal theory of the unconscious made the trauma of sexuality innate and primordial, giving proper primacy to what Freud called psychic reality. What today’s consumer culture veils, precisely in its commodification of sexuality as a lifestyle choice and a right to endless enjoyment, is the darker but more properly Freudian point: namely, that human sexuality is unavoidably traumatic.In a letter to Wilhelm Fliess dated the 21st of September 1897, Freud explicitly abandoned the Seduction Theory (1985). It had become apparent to him that the sexual content arising from free association did Inhibitions, Symptoms and Anxiety (1985), such CBT frameworks tend to reduce anxiety to a once realistic fear of empirical danger, the attendant signals of which have been misperceived. It was this understanding of anxiety as an irrational fear of fear that led to the notion of therapeutic ‘immersion’ or ‘flooding’ by means of which an experience that would correct the individual’s relation to reality could be induced. Whether in psychiatric conceptualisations of trauma per se or anxiety, one can discern the influence of behaviourism and a fairly naïve stimulus-response model, and very similar notions are now articulated through the alternative vocabulary of neuroscience and neuronal ‘plasticity’ (Abi-Rached and Rose 2010).Given that the DSM IV classified PTSD as an ‘anxiety disorder,’ it is worth pointing out that one can observe a similarly partial reading of Freud’s ideas on anxiety in some Cognitive Behavioral Therapy (CBT) frameworks. Rather than recognising the psychic reality of a fear without empirical locus, as Freud was careful to do in causality.In these deviations from Freud, sometimes in the name of another Freud, I would argue that what is really at stake, ethically and eventually politically, is two quite incompatible models of then goes on to have pathological consequences such as persistent re-experiencing in nightmares, hyper-arousal and extreme avoidance behaviours. A, that is, leads to B. Because of its historical and institutional links to war, there is much less scope today for the idea that the stressor event could be unconscious. The victim of trauma generally knows what the traumatic event was, and the almost juridical emphasis is on demonstrating the causal link between it and subsequent disordered behaviour. There is something paradoxical, therefore, about ‘trauma talk.’ On the one hand, it foregrounds the horror of the unexpected, the unpredictable, the out-of-the-blue. Yet on the other, it posits a cause-and-effect relation that is determinate enough to make of the traumatised individual a helpless victim of unfortunate circumstances. The circularity, as it were, of this linearity, can clearly be seen in its reversal: a great deal of research now goes into identifying genetic risk factors that predispose for PTSD.In common with Freud’s pre-psychoanalytic Seduction Theory, PTSD conceptualises trauma in terms of a fairly linear, Newtonian—or Pavlovian—causality. In the vocabulary of the DSM, there is an initial ‘stressor event’ which Beyond the Pleasure Principle, of 1920 emerged from clinical work with victims of shell shock after WWI. In it, he both revised the pleasure principle in the face of the repetition compulsion and posited the controversial death instinct. But as usual with Freud’s work, one can find the seeds of these later elaborations even in the earliest writings.However, staying closer to Freud’s properly psychoanalytic abandonment of the Seduction Theory yields a profoundly different model of causality. Freud himself claimed to be constitutively incapable of doing philosophy. While the proximity of some of his ideas to those of Schopenhauer and Nietzsche permit us to doubt him on this score, it was nevertheless his fidelity to his clinical practice, rather than a taste for abstraction, that led him to sketch a non- or anti-Pavlovian theory of psychic causality. The transitional text, nachträglich, or ‘belated,’ nature of Emma’s trauma. If linear causality is retained, it is only by being split in two. The shock of the ‘first’ event is registered in the psychic apparatus but only as a spike of uncathected libido, awaiting its subsequent symbolic cathexis. However, with this splitting of linear causality, Freud had already intuited that Emma’s trauma only came into being retrospectively when a link was made to the ‘second’ experience at age thirteen via the common trait of the leering smile: her phobia was thus a response to what registered as traumatic only après-coup. In other words, B leads to or gives rise to A.Let us take the case-study of ‘Emma’ again. Already, Freud had recognised a recursive relationship between the two elements that Emma, after analysis, was able to bring in to relation: intuitively, we would place the inappropriate touching she, at the age of eight, experienced at the hands of the shopkeeper as the ‘stressor event’ that then led to a pathological manifestation five years later at age thirteen when she felt immense anxiety on perceiving that two shopkeepers laughed at her for no discernible reason. A seemingly leads to B, then. But Freud focuses on the gap of five years between these two events and thus on what he terms the To understand fully this aspect of Freud, it is necessary to turn to a much more philosophically inclined psychoanalyst, Jacques Lacan. More than any other thinker in the twentieth century, Lacan understood trauma as a ‘textuality,’ thus as adhering to what he called the ‘logic of the signifier.’ Whilst this logic separates word from thing, opening up a hole in the speaking being’s world and suspending naïve notions of ‘reality’ and its causal laws, it also makes this structural trauma amenable to symbolic treatment. Lacan develops this position at various points in his work.truth that language can never fully capture. In a 1945 publication, entitled ‘Logical Time and the Assertion of Anticipated Certainty’ (2006b), Lacan drew amazingly early on game theory in order to bring out the recursive causality already implicit in Freud’s notion of nachträglichkeit. Using a complex thought experiment that there is not space to go into here (see Wright 2018 for an account of it), Lacan showed that even rule-bound, logical puzzles can only really be resolved by subjects who act, not because they subordinate themselves to the rules of the game, but because, in and through acting, they retrospectively create the certainty that allows them to leap into the unknown. In his second seminar of 1954 and 1955, he returned to the problem of causality, this time making use of cybernetics and information theory (1991). His fifteenth seminar would be entirely devoted to the psychoanalytic act, contrasting the conditioned causality of Pavlov’s dogs with Caesar’s crossing of the Rubicon (1982). However, I will concentrate here on what Lacan says about causality in his eleventh seminar, The Four Fundamental Concepts of Psychoanalysis (1994), held between 1963 and 1964.In a 1946 paper entitled, ‘Presentation on Psychic Causality’ (2006a), Lacan vehemently attacks Henri Ey’s alleged organic determinism, appealing instead not just to psychoanalysis but to philosophy in order to make a distinction between, precisely, reality and truth. For human subjects, he argued, psychic causality is not a matter of the quantifiable reality physics has been able to model so impressively but rather, of a subjective Metaphysics, where a distinction is made between two types of causality, automaton and tuché. These two terms have generally been translated—erroneously, according to Lacan—as fortune and chance respectively. ‘Automaton’ refers to a kind of machinic unfolding familiar today in the idea of a programme that runs, implicitly in a kind of loop and produces predictable results. Classically, we might conceive of automaton as fate which various Greek tragedies showed cannot be avoided. ‘Tuché,’ however, corresponds to a totally unpredictable encounter with what Lacan calls ‘the real,’ a concept which must not be confused with reality . If experienced reality is reassuringly meaningful, predictable, automatic even, the real is incompatible with any such symbolic co-ordinates: it cannot be predicted or represented or spoken fully, even after it has burst forth. This is why Lacan will later invent the neologism, ‘troumatisme,’ with ‘trou’ meaning hole. An irruption of the real in the midst of what had been our reality, trauma tears a hole in the very fabric of meaning. As horrifying as this can be, tuché can nonetheless be an experience with transformative implications that the subject can assume as her own. Fate can be replaced with a destiny that is in some sense subjectively chosen, as figured by Caesar’s crossing of the Rubicon. Tuché is not raw chance then, but an event, an always missed encounter, in the wake of which, the unconscious has the opportunity to construct something new.In that seminar, Lacan undertakes a revision of the theory of causes outlined in Aristotle’s The Interpretation of Dreams (1991). A father suffers at the level of reality an experience which by most standards would count as traumatic: the death of his son. Exhausted, he asks an elderly friend to sit with his son’s body so that he, the father, can get some sleep. He then dreams that his son comes to him and demands, ‘Father, can’t you see I’m burning?’ upon which horrifying image, he awakes. Noises from the room next door alert him to the fact that a candle has, in reality, tipped over and caused a fire, of which the elderly man, who has himself fallen asleep, is completely oblivious. Where should we locate causality here? The common sense model places the cause of the father’s waking in the noises coming from the adjacent room, from reality, where accidents can happen but at least observe the laws of physics. Yet Lacan reverses this assumed relation by insisting that the cause of the father’s waking is to be found in that dreadful phrase, ‘Father, can’t you see I’m burning?’ This question is an accusation, a ‘why hast thou forsaken me?’, which speaks to the impossibility of predicting the real, even for a father who would love to be able to control everything in order to guarantee his son’s safety. “Is there not more reality”, Lacan asks, “in this message than in the noise by which the father also identifies the strange reality of what is happening in the room next door?”. The father’s own interpretation, that it must have been the actual fire that awoke him, is a kind of defensive appeal to reality in order to evade this glimpse of the real which piques his unbearable guilt and remorse. Indeed, in dealing with the actual fire, he gets to make amends, though in a more or less useless way, for what he hadn’t been able to do: to rescue his son from the fever that caused him to ‘burn up’ and die. Of the phrase in the dream then, Lacan says, “This sentence is itself a firebrand—of itself it brings fire where it falls—and one cannot see what is burning, for the flames blind us to the fact that the fire bears […] on the real” (59).Lacan illustrates this distinction through a reading of one of the dreams Freud reports in Crazy Like Us: The Globalization of the Western Mind (2011), specifically his account of PTSD counsellors in post-tsunami Sri Lanka. I will then outline some of the broader acknowledgements of the potential reductiveness of Western psychiatric nosology coming from the fields of critical and cross-cultural psychiatry. Finally, I will conclude by isolating what a Lacanian approach can usefully add to these existing critiques in order to outline Lacan’s potential contribution to the project of the medical humanities.There is always the danger of getting consumed and indeed burned by Lacan’s rather beautiful and yet often dazzling rhetoric, so I will close by bringing out what I believe to be at stake in the psychic causality he is dramatising here. I will do so, firstly, by referring very briefly to Ethan Watters’ excellent book, In the second chapter of Watters’ book, he describes a veritable army of trauma counsellors and researchers who raced to the scene of devastation within days of the tsunami striking Sri Lanka in 2010, convinced that a ‘second tsunami’ of PTSD was inevitably going to hit the country in the coming weeks. He argues that the image of this ‘second tsunami’ was sufficiently potent to mobilise an enormous therapeutic apparatus. So-called traumatologists speculated wildly in the international media, predicting that between 50 and 90% of the affected population would develop symptoms of PTSD and that up to 30% of those would be at risk of suicide (Watters 2011). Thousands of what one Sri Lankan called ‘parachute researchers’ were soon on the ground, conducting interviews and surveys, organising psychological debriefings and encouraging children to symbolise their distress through drawing and play. Some even randomly handed out anti-depressants as if the packets of pills were on a par with food aid packages.Exposing the extremely problematic imbrication of clinical practice with the simultaneous production of a self-justificatory evidence base characteristic of much Western medicine (though perhaps CBT pre-eminently), Watters persuasively argues that this emergency ‘therapy’ was inseparable from the production of data. For example, ‘research’ on the extent of PTSD prevalence in Sri Lanka was conducted even before the time period—clearly specified in the DSM-IV’s diagnostic criteria—of at least one month of persistent symptoms. In this sense, the long juridical tradition of ‘emergency powers’ that suspend civil law in times of war or natural disaster was extended to the psychiatric laws codified in the DSM itself. The enormous humanitarian enterprise that was thereby able to unfold, clearly motivated by genuinely good intentions, was also driven by an urgent belief that human responses to trauma are universal and therefore homogeneous. The organism, whether in Sri Lanka or Seattle, was supposed to respond to traumatic stimuli in fundamentally the same way. Directly related to this confidence in an established and universal cause-effect relation, these volunteers were also imbued with a faith in Western medicine’s capacity to identify, intervene, and alleviate a standard checklist of PTSD symptoms. And yet, many trauma experts and researchers in Sri Lanka were soon confused to find that, though clearly shocked, bewildered and distraught, many victims of the tsunami did not conform to conventional PTSD criteria. Their interpretation of this finding? These people were clearly in denial.Watters rightly points out the view of PTSD that these well-intentioned counsellors and researchers brought with them steamrollered the particularities of the Sri Lankan cultural context. I would argue this has a great deal to do with its implicitly Pavlovian causality in turn buttressed by behaviourist assumptions which nourish a particular view of what subjects are and how they should be governed. Yet Watters also notes that Sri Lankan culture, partly because of its long civil war, already includes considerable resources for dealing with trauma, from Hindu and Buddhist religious traditions to an emphasis not on the individual ‘resilience,’ ‘flourishing’ or ‘growth’ now favoured by positive psychologists but on group support and community relations. The very idea, then, of what a subject is and how he responds to distress, was fundamentally different.In making these points, Watters is drawing on critiques of mainstream western psychiatric nosology that have already been mounted within comparative cultural psychiatry, often based on medical ethnography and anthropology. Shortly after the DSM first included PTSD in 1980 for example, Allan Young was already conducting ethnographic work with Vietnam veterans in the US which, he argued, showed that both ‘traumatic memory’ and PTSD were essentially discursive constructs enabled by institutional powers and practices, rather than transhistorical noslogical entities (Young 1997). Derek Summerfield has also argued that PTSD had a specific sociological function in the post-Vietnam US context, primarily that of re-presenting soldiers not as ‘baby killers’ who should be blamed for the atrocities of the war but as victims of a warmongering US government and therefore deserving of help and support (Summerfield 2001). The instrumental political utility of this category, seemingly present from its origins, has only become more transparent as it has become globalised. For precisely as neoliberal models of globalisation spread in the 1990s and a corresponding doctrine of supra-national human rights was given institutional form, PTSD started to be integrated into ‘human rights’ interventions in post-conflict situations outside the ‘west.’ Well before the Sri Lankan disaster that Watters details, the United Nations and the World Health Organisation had already jointly advocated the training and deployment of hundreds of ‘trauma advisors’ in the former Yugoslavia, and UNICEF launched a similar programme in post-genocide Rwanda aimed at traumatised children (UNICEF 1996). What I have called the ‘Pavlovian’ causality of PTSD then, as conceptualised and implemented in post-conflict relief programmes from the 1990s onwards, perhaps reduces suffering but certainly  does reduce agential subjects to the status of more or less passive victims. Such victims can then be said to be in need of better government than their ‘failed states’ could apparently provide. Trauma talk can thereby play its part in neoliberal forms of governmentality.political contexts into the notion of traumatic causality, which the narrowly biological framework tends to radically downplay. However, there are also some limitations with this kind of work which, I would suggest, can be productively negotiated by entering into dialogue with the Lacanian approach. Firstly, cultural psychiatry runs the risk of sliding into a cultural relativism that has the potential to leave traumatised subjects alone with the resources supposedly available to them, even when research has shown that post-traumatic anxiety in non-western contexts often centres on very practical, material concerns of daily living which cannot be addressed by cultural and communal frameworks alone (Wilson and Drozdeck 2004). Secondly, cultural relativism, sometimes unconsciously tinged with exoticism, can also conflate individual experience with much broader anthropological assumptions, as if individuals were always prototypes of their cultures: clearly, this gesture is not innocent of the very universalising zeal that motivates the DSM . Thirdly, whilst the importance of the cultural dimension is rightly stressed over and above a putative biological universality, underlying assumptions about causality often remain intact: the stimulus-response model, for example, can be retained alongside an acknowledgement of the cultural diversity of responses. At its worst, the ethical and political question of causality I have focussed on here is sidestepped by recourse to a crude ‘Foucaultian’ social constructionism that effectively replaces the notion of a traumatogenic stimulus or cause with a knowledge/power nexus within institutionalised medicine.More attuned to cultural differences and cross-cultural miscommunication than the makers of the explicitly globalising DSM, critical psychiatrists have tried to contest the homogenising effects of the biological model of PTSD, both by pointing out the cultural specificity of ‘presenting problems’ in diverse locales and by formulating alternative descriptors which incorporate the socio-cultural dimension such as Kleinman’s notion of ‘social suffering’ (1997) and Eisenbruch’s ‘cultural bereavement’ (1991). These are important interventions that go a long way towards reintroducing not just social and cultural factors but crucially tout court for Lacan) and also the more facile aspects of constructionism . Thus, as early as the 1950s, Lacan was drawing on the structuralist anthropologist Claude Lévi-Strauss to argue that cultures are symbolic systems that effectively treat, through myths and rituals, a fundamental contradiction or impossibility that he himself would go on to call the ‘real’ (Lévi-Strauss 1969). Just as Lacan argues that subjects are already responses to the trauma of sexuality and castration in language then, so he agrees with Lévi-Strauss that cultures are similarly unique responses to a traumatic kernel and should be honoured as means of treating the real. From a Lacanian perspective, with speaking beings shaped by their cultural contexts, one is always dealing with a symbolic, and therefore recursive, causality that allows suffering individuals to transcend the status of victim of an unfortunate reality, to become subjects of their own speech. But to discern that singularity, one has to listen, not talk. This Lacanian perspective has a great deal to offer to the medical and/or heath humanities, which likewise aims to honour the testimonies of patients as a form of experiential evidence that, if attended to, can humanise some of the clinical and conceptual frameworks associated with ‘objective’ disease models of illness.Lacan’s emphasis on the role of language and the impact of the logic of the signifier on psychic causality both underlines and enhances critical and cultural psychiatry. After all, Lacan’s emphasis on the symbolic dimension enabled him to avoid relativism : 673-80.Eisenbruch, Maurice. 1991. “From Post-traumatic Stress Disorder to Cultural Bereavement: Diagnosis of Southeast Asian Refugees.” Freud and the Scene of Trauma. New York: Fordham University Press.Fletcher, John. 2013. Power/Knowledge: Interviews and Other Writings, 1972-1977. Translated by Colin Gordon. London: Harvester.Foucault, Michel. 1980. The Standard Edition of the Complete Psychological Works of Sigmund Freud: Early Psychoanalytical Publications (Vol. 3 – 1893-1899), translated by James Strachey, 143-156. London: Hogarth Press.Freud, Sigmund. 1962a. “Heredity and the Aetiology of the Neuroses.” In The Standard Edition of the Complete Psychological Works of Sigmund Freud: Early Psychoanalytical Publications (Vol. 3 – 1893-1899), translated by James Strachey, 162-185. London: Hogarth Press.-----. 1962b. “Further Remarks on the Psych-Neuroses of Defence.” In On Sexuality: Three Essays on the Theory of Sexuality and Other Works. Translated by James Strachey. Harmondsworth: Penguin.-----. 1977. On Psychopathology: Inhibitions, Symptoms and Anxiety and Other Works. Translated by James Strachey. Harmondsworth: Penguin.-----. 1985a. The Complete Letters of Sigmund Freud to Wilhelm Fliess, 1887-1904. Translated by Jeffrey Masson. Cambridge Mass: Harvard University Press.-----. 1985b. The Interpretation of Dreams. Translated by James Strachey, London: Penguin.-----. 1991. Beyond the Pleasure Principle and Other Writings. Translated by Mark Edmundson. London: Penguin.-----. 2003. Studies in Hysteria. Translated by James and Alix Strachey. London: Penguin.Freud, Sigmund and Breuer, Josef. 1991. Social Suffering. Berkley: University of California Press.Kleinman, Arthur, Veena Das, and Margaret Lock, eds. 1997. Seminaire XV: l’Acte Psychanalytique. Paris: Éditions du Piranha.Lacan, Jacques. 1982. Seminar II, The Ego in Freud’s Theory and in the Technique of Psychoanalysis. Translated by Sylvana Tomaselli. London: W. W. W. Norton and Company.-----. 1991. Seminar XI: The Four Fundamental Concepts of Psychoanalysis. Translated by Russell Grigg. London: Penguin.-----. 1994. Écrits: The First Complete Edition in English, translated by Bruce Fink, 123-158. London: W. W. Norton and Company.-----. 2006a. “Presentation on Psychic Causality.” In Écrits: The First Complete Edition in English, translated by Bruce Fink, 161-175. London: W. W. Norton and Company.-----. 2006b. “Logical Time and the Assertion of Anticipated Certainty.” In Elementary Structures of Kinship. Translated by James Harle Bell, John Richard von Sturmer and Rodney Needham. London: Eyre and Spottiswoode.Lévi-Strauss, Claude. 1969. The Assault on Truth: Freud and Child Sexual Abuse. London: Flamingo.Masson, Jeffrey. 1992. Never Let a Serious Crisis Go To Waste: How Neoliberalism Survived the Financial Meltdown. London: Verso.Mirowski, Phillip. 2013. Neoliberal Governance and Health: Duties, Risks and Vulnerabilities. Quebec: McGill-Queen’s University Press.Polzer, Jessica and Elaine Power, eds. 2016. Inventing Our Selves: Psychology, Power, and Personality. Cambridge: Cambridge University Press.Rose, Nikolas. 1998. Flourish: A New Understanding of Happiness and Well-being – and How to Achieve Them. London: Nicholas Brealey Publishing.Seligman, Martin. 2011. The British Medical Journal 322:95-98.Summerfield, Derek. 2001. “The Invention of Post Traumatic Stress Disorder and the Social Usefulness of a Psychiatric Category.” The State of the World’s Children. Oxford: Oxford University Press.UNICEF. 1996. Crazy Like Us: The Globalization of the American Mind, London: Robinson Books.Watters, Ethan. 2011. Broken Spirits: The Treatment of Traumatised Asylum Seekers, Refugees, and War and Torture Victims. London: Roultedge.Wilson, John P. and Boris Drozdek. 2004. Subjectivity 8 (2): 93-101.Wright, Colin. 2015. “Consuming Habits: Today’s Subject of Addiction.” In Lacan and the Posthuman, edited by Judith Roof and Svitlana Matviyenko, 67-88. London: Palgrave Macmillan.-----. 2018. “Lacan’s Cybernetic Theory of Causality: Repetition and the Unconscious in Source Code.” The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. New Jersey: Princeton University Press.Young, Allan. 1995.


Yet, the results showed that only a few companies have already put some WPHP measures into practice. Likewise, the implementation of healthy leadership is rather limited to date. (4) Conclusions: At present, companies are still more likely to delegate responsibility for employee health and well-being to their staff, having not fully realized the potential of healthy leadership and organizational health promotion. There is great potential to increase WPHP measures on the employer side, through both healthy leadership and supporting WPHP measures.(1) Background: Increasing stress levels at the workplace constitute a concerning organizational trend, challenging not only employees but also organizations alike, as it is in most instances associated with increasing workloads. In consequence, employees have started to demand that organizations begin to accept responsibility for their health and well-being. The present contribution seeks to investigate, to which extent individuals are able to deal with stress and whether their employers and respective supervisors (leaders) accept responsibility for their health, for instance, by leading by example. In addition, the existence and support generated by the organization in form of Workplace Health Promotion (WPHP) is inquired. (2) Methods: Semi-structured qualitative interviews with 40 (full and part-time) employees from two European countries were conducted. (3) Results: The study with employees from Austria and Germany ( Increasing stress levels at the workplace constitute a concerning organizational trend ,2,3,4. TWith the literature excessively documenting the detrimental aspects of employment, such as stress and burnout , organizChanges in Human Resources’ orientation are, first and foremost, conditioned by a paradigm shift, which stresses the necessity to invest in competitiveness (and skilled employees) instead of boosting productivity ,33,34. SIn the following, focusing on an employees’ perspective, we aim (1) to analyze whether employees feel mainly responsible for their own health or whether they see the responsibility for their health to also lie with their employer and (2) to investigate the strategies employees use to establish a sound work-family-balance. While these are the main goals of our study, we also want (3) to explore whether, from an employees’ perspective, companies have already started to implement healthy leadership and (4) to determine which WPHP measures have already been implemented by companies, on the one hand, and how they are perceived by employees, on the other hand.Occupational health as a subject area was first introduced in the 1990s and accounted for the valuable contribution of psychologists to creating a healthy workplace . In geneIn recent years, the term occupational health has been substituted by organizational health . Bauer a(1)Healthy organizations set a clear direction for their future and how they conduct themselves.(2)Healthy organizations are executed well and have a culture of high performance.(3)Healthy organizations create a strong connection between employees and the company by showing appreciation and by bringing meaning to work.Organizational health comprises a number of areas, such as a company’s psychological and financial health. According to Cacace et al. , psycholThese criteria correspond with two recent industry studies, according to which a shift in employee preferences can be observed: “What employees really want isn’t more money but better benefits. They want to work at a place that is really organizationally healthy” ,61. This(1)a balance between job demands, resources, job design, social relationships, and support, as well as change, need to be achieved ,71;(2)organizational offerings need to be tailored to employee needs ; and(3)organizational health must be reflective of organizational climate. Thereby, organizational climate encompasses leadership and management practices, as well as organizational structures and processes ,73.The literature has defined a number of strategies and factors that influence organizational health and suggests thatStrategies to enhance organizational health mainly concern healthy leadership ,75 and wOrganizational health is linked to the concept of organizational politics , and as According to Hänsel & Kaz and Boehm et al. ,24, healIncreasingly, the workplace is recognized as a place in which employees’ health can be improved . The conFollowing the Practices for the Achievement of Total Health (PATH)-Model, healthy workplace practices can result in both employee and organizational health; thereby, both components are dependent upon each other . A similAs part of a modern change management that focuses on the workforce and their individual needs respectively, companies are required to listen actively, create a healthy work environment, provide benefits that correspond with personal needs, and engage their employees pro-actively in order to make their business thrive and convince employees that their business is the best place to work . WorkplaOrganizations can affect health in a variety of ways—for instance, through material, behavioral, and physical mechanisms . In the The focus of the empirical study concerned healthy leadership and employee well-being in the digital workplace. Based on the previously outlined generic organizational health framework by Bauer and Jenny ,53 and tBesides individual strategies of dealing with this dichotomous approach to health, the empirical study aims to determine whether employees feel that companies increasingly step up and recognize the workplace as a place where individual health can be enhanced. As such, it is proposed that organizations draw from their health promotive capacities.In detail, the study examines, from an employees’ perspective, (1) whether employees themselves perceive to be in charge of their health and (2) the strategies they utilize to manage the often contradictory requirements of their private and professional lives , (3) whether companies have already established a healthy leadership and whether their leaders model healthy lifestyles, as well as (4) whether employers have already implemented WPHP measures. If this is the case, we also seek to uncover how employees evaluate the respective WPHP measures. Hence, the relevance of individual as well as organizational strategies to optimize individual and organizational health is scrutinized.n = 19) did not have a management position. The average interview time was 35 min.Semi-structured qualitative interviews with 40 (full and part-time) employees from two European countries (Austria and Germany) were conducted over the course of two months. We used purposeful sampling in order to recruit interview partners that could provide in-depth and detailed information on healthy leadership and workplace health promotion . For thiA qualitative research approach was chosen, as, instead of confirming existing research findings, the main focus of the chosen method is to get new insights . The intSemi-structured interviews were used in order to give the interview partners freedom to elaborate on selected aspects ,113,114.The fully transcribed interviews were saved in text format. All interviews were uploaded to QCAmap and analyzed using both a deductive and inductive approach. The analysis was deductive in that it tried to find support for the previously introduced topics, investigating the extent to which previous research findings are supported. We did so by assigning interview passages to pre-defined categories based on the literature—the categories were also reflected in our interview guideline. The analysis was, however, also inductive, as we tried to identify aspects that have not been thematized by previous research to date. In addition to inductive/deductive coding, we also were able to report the frequency of elements. A summary of the most important themes together with exemplary quotes can be found in The content analysis was conducted by two independent coders. The individual coders were trained by the authors on how to code variables along the specific categories. The codebook was refined on several occasions to account for the additional insights that emerged during the training process. When coders had reached acceptable levels of reliability , they coIn a first step, we asked participants about the relevance they attribute to their health and, also, who they think should be responsible for their health. To the largest part, individuals attested that they were in charge of their health. Exemplary statements read as follows: “I am responsible for my health, I would say” , “I am solely responsible for my health” , and “I pay a lot of attention to my health and try to improve it on multiple occasions” . While “everyone is responsible for their own health” , there was also agreement that individuals are able to improve their health and well-being more readily, “because these days, you have many opportunities to take care of yourself” . One respondent, nonetheless, remarked that his health was subject to environmental influences, including the workplace .When inquired as to how participants took care of themselves at work, several measures were listed, such as “getting up and moving around in-between work. Taking the steps instead of the elevator” , “take enough breaks, eat on a regular basis” , or “go outside for a bit” . One interviewee even mentioned that he learned how to “sit in front of the computer for 8 h, or how can I practically strengthen my eyes” . In one company, exercise was not an individual but a team effort: For example, the employees said “Let’s go up a few floors” or “Let’s take some exercise. That’s convenient” .integration. One employee stated that “with the modern technologies, it is very hard to separate work from home” . Respondents attested that work presented a central component of their private lives, forcing them to integrate work-related aspects into their homes on a regular basis. Conditioned by the omnipresence and broadening scope of new technologies, the two spheres are “more and more connected because with these new tools, like mobiles, where you get your emails, and it gets more complicated to really disconnect” . This also held true for an employee from the banking industry, who observed his own inability to “escape it. Your work will influence your private life and your family will feel that you are not content and preoccupied with job-related matters” .Strategies to establish a healthy work–life balance entailed, for example, flexible working hours . In the context of work flexibilization, the largest proportion of employees indicated that separating their private from their professional lives was quite challenging, opting for an One interviewee described it as a “balancing act, since the company is always very present in the private sphere. One does additional tasks. But it is exactly the other way around as well: it is possible to organize and do private things in the workplace” , while one extreme case even forced an employee to attend to job-related matters during his honeymoon, attesting to his inability “to separate the two areas” ; another employee held a more relaxed attitude towards the subject matter: “Of course, it happens that I go for a drink with my work colleagues after work and that we talk about work. But I also think, yes, that’s just part of it, because that’s everyday life, work is part of your everyday life and you talk about it, too.” .adaptation. Since “it is very important for me to separate these two” , individuals have to take action themselves to guarantee a break from work. While individuals can, allegedly, “at a certain level, […] adjust your life around the company” , for others, it is not as easy. One interviewee, who is a sales manager, remarked: “It was quite difficult to draw a line in the beginning, because you just go into the stores in a different way. So that’s certainly the problem, that somehow you always know that you are in a market where an employee of yours works. But you learn to live with it” . Another employee shared: “Until January, I actually worked from Monday to Friday, and my life has been sacrificed to the employer—no let’s say my life belonged to my employer. And now, through teleworking, I have 2 days a week when I can do things for myself, when I have time for the family and that’s very important for me” .However, not all employees are content with integrating their professional lives into their private lives; instead, they decide to take pro-active action to ensure that the two spheres do not mix. This is commonly referred to as separation of the two areas is possible. In these instances, even employers ensured employees’ ability to disconnect from work, e.g., by not grating them the possibility to access work-related information from home. A female respondent expressed appreciation for this regulation, claiming that “you leave the office and only think about work when you come back the next morning” . This, however, did not constitute the norm, as others were forced to take matters into their own hands. For example, one employee postulated in order for his work not to interfere with family time: “I got myself a private cell phone” . Another said: “I try not to work at home” . This notion is shared by another interviewee: “At first, I couldn’t keep my work and private life separate, because I was doing a lot of work at home. But now I know, that if I go to the office, I do my job and if I go home, I don’t do a lot of work at home, so it helps me, to keep it separate” .In some instances, a Mixed results were reported with regard to the extent organizations in general or managers in particular expressed concerns for employee health. While some respondents claimed that health was not an organizational issue, announcing that “in my company, health doesn’t play any role” , or “my employer does not play any role in my health” , other employees reported more positive experiences. In line with the observation that “my environment can also influence my health” , one female respondent, who works in education, stated: “At my workplace, it is great. We have an own department that deals with health promotion and management. And there are many offers I can choose from, provided I take advantage of them” .At times, managers take a hands-on approach to health as well. One employee claimed: “My boss is one of those people, who puts a carafe of water on my table when I cannot get any. So he most certainly takes care of his employees” . Another respondent stated that their work canteen offered healthy food, and “our boss often joins us for a healthy meal” . In other cases, the whole department attends gym classes together, and that also includes the top management . One interviewee shared a very positive example: “My superior offers weekly appointments where you can come to her with concerns, but you can also talk with her about stress and she helps us when she recognizes that we can’t deal with the situation ourselves” . Through healthy leadership, managers can positively shape responses to organizational offerings and lead through their own behaviors, thus functioning as role models.Albeit both employees’ concern for their health and calls for employers to take responsibility for individual health are on the rise, notions of how health in the workplace can be improved are quite diverse . Sixty percent of all respondents indicated to have benefitted from corporate initiatives and showed appreciation for what they had been offered so far. Corporate WPHP measures, for instance, involved the provision of free fruits and vegetables , free health checks and vaccinations , comfortable chairs and a pleasant office atmosphere , and gym classes/memberships either free of charge or at a reduced fee .When inquired about the relevance of WPHP measures related to a work–life balance, employees did not fail to express the importance of separating their private lives from their work lives. While respondents claimed it was definitely easier to keep the two areas apart for some industries , personal efforts alone would not suffice but need to be complemented by corporate measures . While employers only stepped up in selected cases, ensuring that e.g., employees were unable to access the work content from home , or even offering an employee some additional flexibility after he had become a parent  , similar corporate steps were also reported by a service industry worker, who reckoned: “They give you extra vacation up to two days a year so you can do good social things like helping in the kindergarten. They also give you an extra day for your birthday which you can use flexibly—meaning you have plus/minus a week to take it” . An alternative would be appointing a deputy in chief, who then attends to matters . These incentives, however, do not present the norm yet. Overall, employees feel like there is room for improvement, stating that they would appreciate small steps, such as the opportunity of telecommuting .Our study showed that employees attach a great importance to their health and confirmed that present-day conceptualizations of organizational health have to take shifting priorities on part of employees into account . ThThe study further confirmed that employers have begun to recognize the potential of the workplace as an environment, where individual health can be enhanced ,93. SeveLikewise, our study validated that social relations with other team members or employees hold a health-enhancing capacity. Referring to social capital theory, strong support from or social relations with leaders and other peer group members can increase individuals’ feelings of support and empowerment . TherebyAs Bauer and Jenny ,54 rightOne striking result brought about by the present survey, however, was that one solution does not fit the requirements of an ever more diverse workforce; instead, individuals’ needs and preferences have to be accounted for. As the workplace is undergoing some rapid changes, employees’ motives are shifting too, which might be conditioned by the broader set of skills required in the digital workplace . Hence, This also suggests that employees’ preferences and motives need to be evaluated against the background of changing lifestyles and values . HoweverBased on our study findings, and in line with developments witnessed during COVID-19, flexibility and the option of remote work have been found to benefit employees tremendously in combining their private and personal lives. Amidst the turmoil brought about by the health crisis—and the consecutive labor disruptions—organizations have started to implement solutions that do not require employees to work in physical proximity. According to PwC , 83% of Right now, as our study with employees has demonstrated, employer concern for employee health and well-being is an add-on rather than a given; and while corporate efforts are slowly surfacing—and will presumably be intensified in response to COVID-19—steps towards a truly supportive organizational culture that is based on an understanding of employees’ needs have to be taken more proactively. While notions of organizational health are subject to environmental conditions and, as such, likely to change , organizIf organizations attempt to implement a “culture of health and well-being”, which is supported by “the institutional, social and physical environment” , a more Our study provided useful insights into employees’ perceptions of who is responsible for their health, as well as insights into healthy leadership tendencies and WPHP measures, which have already been established by companies in Germany and Austria. Yet, there are several limitations to the study presented in this paper, which offer directions for future research.Our study looked at employees’ perspectives only; therefore, it would also be of interest to incorporate the employers’ perspectives. It would be also interesting to extend the study to other countries and to compare the establishment of healthy leadership and WPHP measures in different countries. For example, a recent industry survey showed that most U.S. American companies claim to only invest in very basic health strategies, meaning they only offer healthcare benefits or health initiatives but do not really pursue a healthy leadership approach .In addition, future researchers could take possible moderators into account, such as cultural differences. The GLOBE researchers House et al.  identifiOur study was conducted prior to the COVID-19 pandemic. As the pandemic is likely to increase economic and job uncertainty and, with it, has detrimental effects on employees’ psychological well-being ,143, anoFor our study, we chose a qualitative approach. Future researchers might want to use additional methods, e.g., it would be interesting to conduct a quantitative survey or expert interviews with executives from different companies.We asked participants about their perceptions of already established WPHP measures and also inquired desired measures; however, the results could not be explored in detail in this paper, as it would exceed the scope of our paper. A selected set of recommended measures, however, is reported in Future researchers might also want to focus on sociodemographic factors, especially those that influence individuals’ work–life balance such as gender, children in the household, or relationship status.


Multi-sectoral coalitions focused on systemic health inequities are commonly promoted as important mechanisms to facilitate changes with lasting impacts on population health. However, the development and implementation of such initiatives present significant challenges, and evaluation results are commonly inconclusive. In an effort to add to the evidence base, we conducted a mixed-methods evaluation of the Claremont Healthy Village Initiative, a multi-sectoral partnership based in the Bronx, New York City. At an organizational level, there were positive outcomes with respect to expanded services, increased access to resources for programs, improved linkages, better coordination, and empowerment of local leaders—all consistent with a systemic, community building approach to change. Direct impacts on community members were more difficult to assess: perceived access to health and other services improved, while community violence and poor sanitation, which were also priorities for community members, remained important challenges. Findings suggest significant progress, as well as continued need. In low-income communities that have experienced decades of disinvestment from the public and business sectors, interventions with a limited focus on individual behaviors and health conditions—and with a short time horizon—are unlikely to have substantial impacts on population health or its determinants , 2. BroaIn an effort to add to the evidence base regarding multi-sectoral collaborations, we conducted mixed-methods evaluation of the Claremont Healthy Village Initiative (CHVI), which is a coalition based in Claremont, a section in the Morrissania neighborhood of the Bronx, New York City (NYC). Claremont is a low-income community with disproportionately high rates of poor health and premature mortality: 31% of Claremont residents live in poverty, 16% are unemployed, and 36% do not have a high school degree. Twenty-two percent of adults in Claremont have diabetes and 36% are obese. At 76.2 years, life expectancy is 5 years shorter than the NYC average .Founded in 2012, CHVI is a partnership that brings together residents and multi-sectoral institutions to integrate programs and services to address the broader determinants of health, improve quality of life, create synergies that promote health and reduce inequities, and foster collaboration. Anchored by BronxCare, which is a local hospital, and Healthfirst, a not-for-profit managed care organization (MCO), partners include local tenant associations, community and senior centers, civic groups, public schools, arts and cultural organizations, sports and recreation groups, and NYC governmental agencies. These organizations collaborate on the design and delivery of programs, outreach to community members, and implementation of service activities .CHVI is not a legal entity and lacks a hierarchical structure for decision-making. Rather, CHVI encompasses and supports a broad range of programs and activities developed and/or promoted by community stakeholders, including health fairs, exercise classes, a youth leadership council, anti-violence events, neighborhood clean-ups, cooking classes, health education , and programs in the visual arts. CHVI hosts regular stakeholder meetings to facilitate collaboration and the exchange of information. CHVI also publishes a newsletter for community members that include information on community programs and activities; “spotlights,” describing local organizations and individuals; general announcements; and a job listing.The evaluation, which was conducted from 2016 to 2018, used a mixed-methods approach to assess changes at the individual, organizational, and community level. It included interviews with staff from the two anchor institutions and key partnering organizations (referred to jointly in this study as “stakeholders”), focus groups and surveys with community members, a survey of CHVI partner organizations, and an analysis of health insurance claims data. The findings reported here focus on community perceptions of program effects, and, as such, the results rely on data from the interviews, focus groups, and community member surveys only. The protocol was approved by the Institutional Review Board of The New York Academy of Medicine.n = 25) and end (n = 6) of the evaluation. Interviewees represented a range of institutions and individuals working in Claremont, including the MCO and hospital that founded the initiative; a senior center; a community center; tenant associations; NYC government agencies; a philanthropic organization; health care providers; and CBOs focused on youth, physical activity, healthy food access, and the arts. Interviewees were identified by the CHVI project leads, by the interviewees themselves, and through evaluator attendance at CHVI project meetings and activities. Both rounds of interviews included questions on engagement in and perceptions of CHVI, CHVI impact on community members and institutions from the time the initiative was launched, strengths and challenges, and recommendations for the future. The second-round interviews focused on changes occurring in the prior 2 years, since the start of the evaluation. Interviews were conducted in person using a semi-structured guide and were approximately 1 h.Stakeholder interviews were conducted at the start (n = 94), including two comprised of youth and young adults, exclusively, and one with older adults. Participants were primarily female (65%), Black (80%) or Latinx (15%), and residents of public housing (62%). Ages ranged from 14 to 65 (mean = 49). Focus groups used semi-structured guides, including questions on health concerns in the community, health care access, community resources, and CHVI engagement. They were 60 to 90 min in length, and participants received $25 in cash.A total of seven focus groups were conducted with Claremont residents  were completed at community events and outside a neighborhood center. Eligibility was limited to Claremont residents (as determined by zip code), age 18 and older. The majority of participants were female (55%), Black (63%) or Latinx (34%), and residents of public housing (69%). Ages ranged from 18 to 83 (mean = 48). Survey data were analyzed using IBM SPSS software (version 19).An in-person community member survey was conducted over nine visits to Claremont between May 2017 and July 2018. The survey included questions on demographics; resident awareness and engagement with CHVI; health and health behaviors; community characteristics and services; perceptions of trust within the Claremont community; and community change over the prior 3 years, which—according to the CHVI leads—was the timeframe for the launch of potentially observable community programming. Questions on trust were adapted from the Integrated Questionnaire for the Measurement of Social Capital . A transBelow, we describe stakeholder and community member perspectives on CHVI impacts. We focus first on organizational impacts, including changes in community programming and resource availability. Subsequently, we describe perspectives on outcomes specific to the health and well-being of individuals living in Claremont.Participants in key stakeholder interviews described the CHVI collaborative process, which included regular meetings open to all partners, outreach and engagement by individual staff, as well as ongoing and consistent communication resulting in the development of sustainable working relationships. An important component and strength of CHVI, as described by stakeholders, was the involvement of community members in the process, as well as the elevation and cooperation of local Claremont leaders, most notably tenant association presidents.I think we have really good communication. … my contact over at [the hospital], and we're in probably weekly conversation to make sure. And I think also that it's ongoing, you know, in the goals to make something sustainable. (Stakeholder interview)[Community members] have been very involved, you know. All the people I work with, we call each other, “I’m having this, this, this. Come support me. Help me.” We all know who our leaders are, and also we trying to get more people to come on board to become leaders. (Stakeholder Interview)I would say [a strength] is the involvement that they've gotten from leaders in the community. Like the tenants' association presidents and stuff. That's no small feat. (Stakeholder interview)Stakeholders also described the variety of CHVI-affiliated programs and services their organizations offered, as well as the perceived benefit to community members, including increased knowledge and awareness and improved access to activities that promote health and wellness.I think that you've got to realize … that conversations about healthy eating and exercise don't exist in the South Bronx. I've lived here for years and I've never even heard a conversation like that. So, the fact that they're introducing this, that they're just getting people thinking about it. That they are doing events around it. I think there is some ripple effect. (Stakeholder interviewee)The Urban Ambassadors, so here, that has been successful, has had an impact. And not only have we had, let’s say, sixty kids go through leadership development, it’s also been a lever to affect kind of the priorities of those organizations and of the neighborhood, so introducing the idea about healthy living, right your path, getting people to think about their careers… so those types of things. (Stakeholder interview)It's good because the community – there's so much going on and you don't expect one event or one thing to satisfy all the community. Whether it's youth service or children's services, something for seniors or something for adults, something that's inter-generational. We have mental health training coming up. There's a lot a moving parts, you wanna get folks out and you don't wanna burn people out. (Stakeholder interview)Several stakeholders attributed their own organizational and program expansion to engagement with CHVI, describing increases in referral networks and linkages to health care services; financial and/or in-kind support provided by the anchor organizations; and connections to outside resources, including funders. In addition, small CBOs described an increase in recognition facilitated by their new affiliations with larger, more established organizations.They brought … the hospital into the community. We now know more services that’s offered in the hospital as a result of being part of the partnership, and some of the benefits that were reaped from this partnership were the fact that now we have home visits for the elderly, and the sick, and infirm, and shut-in from [the hospital]. That was unheard of, but because of conversations, we were able to make that happen. (Stakeholder interview)So, for elected officials, it’s raised our visibility. We had existed in the community for several years. We operated the Beacon Program for fifteen years. We operated at [school name] for eight years. We operated at [housing complex name] for four years. And we had never gotten any type of traction, in terms of funding, from our council person or our state officials. Where now, [our council person] allocated $100,000 for renovations right outside of the community center that needed to be done that hadn’t been done and another $100,000 for capital improvements just to get our internet up to speed. So, that’s helped. And I think CHVI has been a big part of that. And also, another thing I know, just in resources, getting our families able to be part of the [hospital] network, so that they can receive expedited appointments for checkups and physicals and things like that. That’s been helpful. (Stakeholder interview)I would say that the core group of people who have been leading the interactions for the residents have been able to leverage a lot of city and neighborhood resources to participate – to let these people know that, “Yes, you’re a part of the city, and these are all the services that are available to you.” (Stakeholder interview)The majority of community members participating in surveys and focus groups were not familiar with the Claremont Healthy Village Initiative or CHVI per se. However, many survey participants were aware of and participated in activities that fell under the CHVI umbrella. Two-thirds had participated in at least one CHVI-related activity, and many had participated in multiple activities (mean = 3 activities), including the annual family day held at one of the public housing developments, an annual health and wellness fair, and a Christmas event. Focus group participants also engaged in CHVI activities, including mental health first aid training, recreational activities, and educational programs, though in smaller numbers.[The senior center is] really nice. We have a lot of activities and trips. You can learn the computer. There are people who sew and knit and crochet. There are a lot of things to do. I love it here. As soon as I hit sixty, I headed right here. (Focus group participant)We had a program [in this housing complex] about a month ago, and it was a little program about bringing peace. We had an art program. Lovely time. It was very relaxing. Very engaging with the families that came. Children had a very nice time. (Focus group participant)Focus group participants emphasized that additional programming was still needed, as well as better outreach, particularly for youth and older adults.I should not have to go all the way to Harlem for my sons to play football. I should not have to go all the way uptown for my son to get in a basketball program. They need more programs. If we have more positive programs, the children will learn to get along with each other, because they find something that they have in common, so they can actually build instead of looking out the social media. (Focus group participant)They felt that, without sufficient alternatives, youth end up on the internet or “hanging out,” creating an uncomfortable environment for other members of the community. Older adults were described as hesitant to leave their homes because of their fear of the youth.It’s a benefit, but they’re just, you know, they’re not sure… I have to literally take people by their hand and say, “Come on, let me show you what I’m telling you.” I don’t know, how much more where we can make people, especially when you get older, but older people get afraid to come down. Six o’clock PM, “I’m not coming downstairs, and I can’t get back upstairs.” (Focus group participant)Perceived changes to health services available to Claremont residents and changes to community factors that impact health were assessed through community member surveys If we have a youth participant in our program and their grandmother or whomever needs medicine or needs some type of senior service, they're able to – we're able to pick up the phone [to the senior center] and say, "Hey, listen, one of ours needs something that you have, how can we make this work?" And then you throw in the hospital, where they have a whole department for physical health and mental health, that always comes up. And that's always an issue on some level. And so, having that resource, we've been able to pick up the phone or shoot [them] an email and say, you know, "This person needs a physical, this person's medicine isn't being carried or covered by the pharmacy anymore, and can your pharmacy give them something, you know, until this situation is resolved?" Or, “Can you get your health workers to do a presentation to our families on how to eat better, why to eat better?”… That is, I think the strength of their initiative. (Stakeholder interview)A lot of people are more aware of different health and all that stuff. Such as asthma, high blood pressure, or prostate, breast cancer. You know, these people – they’ve been really helping these people out. Because a lot of them found out that they didn’t know that they had such things that were going on. (Stakeholder interview)Increased opportunities to eat a healthy diet and increased activities for youth were reported by over half the survey respondents ; qualitative data suggest a range of opinions, with stakeholders reporting on expanded programing and focus group participants commonly emphasizing continuing needs, as alluded to in the previous section.And so, that’s the way I see our impact is that we may not have a big impact with adults, but for [our organization] and our lens through CHVI, we’re really able to change and positively impact the next generation of Claremont residents to be more proactive and owning their own health, physical and mental health. (Stakeholder interview)In the community member focus groups, violence and sanitation were considered very significant problems, generating extended discussions. As mentioned previously, several participants attributed violence in the community to youth who have insufficient options or are dealing with their anger in destructive ways. Roughly 40% of survey respondents felt that violence had worsened in the past 3 years, compared with 31% who felt it had improved and 27% who felt it had stayed the same. Survey respondents expressed more positive views on sanitation: 42% reported that sanitation had improved in recent years, compared with 30% who felt that it had gotten worse and 29% who felt it had stayed the same.We’ve got twenty-one year-olds, twenty-two, a little younger than that; we got violence going on—robbing, mugging, stealing. It’s sad. That’s what’s going on now. That’s why you see so many cops, and they parking like check points. (Focus group participant)So, you wanna find something get some boxing, get some martial arts, get some self-defense, because they’re angry and they [the youth] need to learn how to redirect their energy when they get angry instead of [using] guns and you know trying to kill each other. (Focus group participant)If you’re here for so long, you’re not surprised by the rats [anymore], like you’re expecting a rat to come out. It doesn’t matter whether it’s daytime, nighttime, it’s just rats. (Focus group participant)Stakeholders and focus group participants described specific expansions in screening and management of disease, as well as facilitated access to health care services.The Claremont Healthy Village Initiative promotes collaborative efforts that support programs and services to reduce inequities and address the broader determinants of health. The intentionally flexible structure provided by CHVI brings together a broad range of institutions and individuals working to improve community health and well-being. The local hospital and MCO serve as anchor organizations, facilitating communication and collaborations that include local tenant associations, community and senior centers, civic groups, public schools, cultural organizations, sports and recreation groups, and NYC governmental agencies. The anchor organizations do not claim or seek control, favoring a more diffuse decision-making process.This evaluation of CHVI suggests positive outcomes at a structural level with respect to access to resources, referral networks and service coordination, empowerment of local community leaders, and expanded programming. These outcomes are consistent with those promoted within a community building approach, which focuses on developing synergies and building capacity of an entire system , 13. TheAt the individual level, outcomes were less evident, which is not surprising given the decades of disinvestment in the Claremont community. As one interviewee noted, “I’d say the realities of poverty still prevail, and undoing … systems that were built contrary to good health … takes a long time.” Due to these historical and persistent challenges, it may take many more years for an effort like CHVI to make a measurable impact on individual health, and the factors that impact it. That being said, it is promising that over half of community survey respondents perceived improvements in access to health services, opportunities to eat healthy, and activities for youth; all of which have been key components of CHVI programming efforts. Lesser progress was made with respect to violence and poorly maintained infrastructure. Although these were not priorities of CHVI at the outset, they are significant concerns of community members and of organizations that are part of the initiative. The slower progress in these areas may suggest a need for supplemental approaches, focused not only on community-based programs but on advocacy and policy change .There were several challenges to conducting the evaluation, which were consistent with the literature on evaluation of coalitions  and reflMulti-sector coalitions are commonly considered to be key mechanisms for addressing health equity and the broader determinants of health. Evaluation results suggest that CHVI, a multi-sector collaboration in an under-resourced neighborhood in the Bronx, has experienced success in terms of building collaborative and synergistic relationships among partner organizations, bringing resources and legitimacy to community organizations, and improving access to health promotion opportunities. These findings add to the evidence regarding the contribution of flexible multi-sectoral coalitions in addressing health inequities and increasing community capacity and connectivity in support of continued progress.