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Published in: Journal of Organization Design 1/2017

Open Access 01-12-2017 | Point of View

How to avoid destroying your employees and organisations due to burnouts, braindrain and fading performance? Stop double bind-communication in your organisation!

Published in: Journal of Organization Design | Issue 1/2017

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Abstract

Absenteeism due to “burnout”, depression or other psychological diagnoses, is increasing alarmingly in modern work life.
This point of view describes presumed connections between the double bind-communication pattern in organisations and its detrimental consequences for both the employees of a double bind-organisation and such double bind-organisations themselves. The employees fall psychologically, psychosomatically or physically ill due to a double bind caused self-esteem-destruction-machinery, the organisations run the risk of self-destruction because the double bind-communication impedes the organisation from learning, evolving and developing new solutions and from adapting to the challenges of changing environments in time.

Introduction

Organisations are facing growing numbers of absenteeism and premature retirements due to psychological illnesses.
Employees are increasingly diagnosed with so-called “Burnout” (which still is only listed under Z73 as general difficulties in coping with life in the ICD-10) or depression thereby making them absent from work for a significant amount of time.
After returning to work it will take a reasonable amount of time until they can live up to their earlier performance status. Sometimes they appear to be completely broken and never attain to their old performance capacities or they may even leave the organisation for ever.
Organisations are thereby not only losing manpower as well as know-how, but also running the risk of abolishing themselfs because a double bind-organisation prevents itself from learning and, as a result, adapting to changing environments.

What is the problem?

Double bind-communication destroys a company’s employees (psychologically, psychosomatically or physically) and, consequently, potentially destroys the organisation itself since a double bind-organisation is impeded from learning and developing.

What is the reason?

For employees, double bind eliminates their self-confidence and morale causing them to fall psychologically, psychosomatically or physically ill due to a double bind-caused self-esteem-destruction-machinery. Double bind-organisations themselves run the risk of self-destruction because the double bind-communication impedes learning, evolving and developing new solutions or adapting to the challenges of changing environments in time. The reason is that one side-effect of double bind-communication consists of ignoring errors as a chance for learning and, moreso, promoting the coverup of any dilemmas resulting from double bind-communication, thereby running a high risk that erroneous top-level-decisions could potentially ruin an organisation.

What are the consequences?

Due to the double bind-self-esteem-destruction-machinery, employees end up “burnt-out” and may suffer physical, psychosomatic and psychological illnesses while ceasing to be productive and valuable performers with all their know-how and experience. If they leave, the organisations suffer brain-drain and loss of valuable resources, potentially causing the organisations to miss their productivity and performance goals. If the employees remain, the double bind-organisations endanger themselves and their existence by causing fading performance, reduced quality and financial losses together with a waning employer branding.

What can be done about it?

Stop double bind-communication in your organisation and implement open, transparent and congruent communication patterns as well as an organisational culture of mutual trust, respect and authentic appreciation together with error-friendliness. Mark mistakes as a valuable learning source which helps both the employees and the organisation to improve and, thereby, enhance the learning ability of the organisation and the company’s results.

What does it take?

Major steps towards stopping double bind in organisations comprise of the following:
  • implementation of a culture of authenticity and authentic communication
  • creation of a culture of attitudes which value all resources of an organisation
  • demonstration of courage on all sides to truly scrutinise processes and question system-routines
  • cultivatation of a culture that supports a focus on objective needs instead of personal goals and gains
  • installation of an atmosphere of mutual trust
Double bind-communication has to be substituted by an authentic, clear, open and transparent communication culture that allows for metacommunication (the communication about the communication), especially to identify any double bind-orders. Additionally, a double bind-free organisation needs to promote attitudes valuing all resources of an organisation. This means that leaders have to know what their employees are best at, where their strengths lie and place them in working environments accordingly. This includes the managers’ knowledge whether an individual employee is content with routine work and receiving (clear) orders or whether another one looks for personal self-improvement and permanent (self-) education. Each of them needs the respective tasks in order to stay motivated and productive. To do all this courage is needed: on the leaders’ and the top-level-managements’ side as well as on the employees’ side. The top-level-management will have to have the courage and will to implement a truly transparent and authentic error-friendly culture embodied by all leaders and managers in the first place but also requested and demanded from all their staff members. The thorough scrutiny of processes and routines within the organisational system should be priority in order to reach constant improvements. On the employees’ side, courage is necessary to name unfeasible orders or dilemmas before they can do harm to people or the organisation. Here, again, the overall culture of the organisation will determine whether an employee fears to point out discrepancies or feels safe to do so. An organisation ready to change will have to stop the well-established double bind-power games which promote only personal goals and gains and will have to substitute them with a common understanding of the objectives required for the holistic prosperity of an organisation, including its goals and all its participants. Last but not least, the necessary adhesive for all this seems to be trust – again on all sides. In the first place on the leaders’ side in the abilities of their people. Where leaders trust in these abilities and know-how and see people’s individual talents as resources for the company’s prosperity, instead of threats to their own power-position, the employees get the leeway necessary for doing their job in the best way. The employees on their end will have to trust (and the daily experience due to a corresponding organisational culture) that their leaders and managers have the employees’ as well as the company’s best interest in mind when setting them goals.

What is Double Bind and how does it work?

The term and concept double bind was shaped by Bateson et al. (1956) who had observed this specific communication pattern to be present in many of their patients’ families where the patients were diagnosed with schizophrenia.
They described it as highly dysfunctional and “crazy-making” and named the following ingredients of a double bind-situation:

Intense relationship

There is a close relationship between two or more persons in which at least one of them highly depends (physically or psychologically) on the other person or the system to sustain the first one. A child depends on its family system. An employee depends on his/her working environment. It is vital in this close relationship to accurately discriminate which sort of message is made in order to react appropriately.

Incongruent messages

The receiver of double bind-messages is caught in a situation where their sender expresses messages on different communication levels, one denying the other. The first message threatens a specific behaviour with punishment – mainly verbally communicated. The second message denies the first one and also contains threats of punishments and is often communicated non-verbally. So, by using the double bind, the sender has already implemented the power to penalise the addressee for whichever behaviour he/she shows because by fulfilling the first order he/she automatically infringes the other one.

Prohibition to comment the mutual seclusion of the orders (no meta-communication)

The addressee of these incongruent messages cannot leave the situation or comment the impossibility of a simultaneous fulfilment of both orders caused by the double bind-spoiled orders. After a while, the addressee might even lose the ability to know on which level (the verbal or the non-verbal one) to respond.

Repeated experience

The constant exposure to the repeated occurrence of the double bind-communication pattern causes the traumatic habitual experience of punishment for whatever move the person takes.

Internalized mental strain after having learnt the double bind-pattern

Once the double bind-addressee will have been exposed sufficiently long to the double bind-pattern any part of the double bind-sequence causes severe mental strain, panic or rage.

Double bind in the organisational context

Bateson et al. (1956) maintained that the psychological effects of double bind were highly dysfuncional and “crazy-making”. First found as a communication pattern in dysfunctional families, double bind can be described as a specific dysfunctional communicational interaction in relationships where persons are dependent on each other. Similar to family systems, organisational systems cannot act without communication and interaction within their system; between its employees as well as external partners such as customers, clients and suppliers. Both contexts are therefore comparable and it is highly likely that the same mechanisms can be found in organisations and companies dealing with double bind-messages which results in the manipulation and control of their staff and so becoming genuine double bind-organisations with highly detrimental consequences.
According to Bateson et al. (1956) and Watzlawick et al. (1967) double bind-messages consist either of
  • incongruent messages carrying verbal and non-verbal signals contradicting each other (giving positive information with a depressed, negative or hostile body language and vice versa) or
  • paradox instructions in one single order (fulfilling the first instruction makes the simultaneous fulfilment of the second one impossible and vice versa)
which makes it impossible for the addressee to decipher a double bind-message correctly. The sender of double bind-messages always has the power to punish the addressee afterwards for any of his/her choices alleging to have meant exactly the other part of the message.
Hinting the discrepancy between the two messages or even just asking which one of the messages (e. g. the verbal or the non-verbal or which part of the paradox instruction) might be the valid one is strictly forbidden. Likewise prohibited is the indication that a simultaneous fulfilment of these two instructions is impossible.
If the addressee nevertheless tries to point out the impossibility of a simultaneous fulfilment of the two paradox messages, the sender will blame him/her according to Watzlawick et al. (1967) with at least one out of these three options:
  • I have made myself absolutely clear. You are just incapable of understanding what I am saying.
    ➩ Meaning: “You are so stupid!”
    Why did you not fulfil order “A” as I have told you to do?”
    ➩ Meaning: You are so insubordinate!
  • What on earth led you to the idiotic idea that I could have meant order “B”.”
    ➩ Meaning: You must be completely insane!
So whatever the employee does, he or she is the one to be blamed afterwards as either stupid, insubordinate or insane or even all three. As a further vital double bind-ingredient, the person cannot leave the situation. A child depends on being supported by its family. An employee normally depends on the income of the double bind-organisation to sustain him-/herself and the family. Thus, in a double bind-system, they end up in a no-win situation.

Traumatising mechanism of double bind in organisations: self-esteem-destruction-machinery – leading via constant frustration and demotivation to burnout and depression

Being constantly exposed to double bind-messages, the employee internalises his or her fear of being punished and, as a consequence, ends up in a psychological state of constant alertness, arousal and unease. Together with the well-known physical side-effects of constant stress, the psychological impact is even more detrimental since, over time, it damages not only the employee’s mental health but, by destroying mental stability, it also causes or aggravates psychosomatic and severe physical illnesses. But the very kernel of the psychologically traumatising effect of this toxic communication-pattern double bind is the systematic or sometimes, for the sake of personal power and superiority, even intended self-esteem-destruction-machinery caused by the double bind-system to which the employees are constantly and – being financially dependent – normally inescapably exposed. Over time, and with accumulative exposure to double bind all three of the accusations of being either stupid, insubordinate or insane, are bound to drive every employee mad – irrespective of how intrinsically motivated, performance-orientated and self-reflected this employee might have been upon entering the organisation. Sooner rather than later (depending on the individual’s resilience and coping abilities) even the strongest personalities and characters will crack under such strain being permanently accused either directly or indirectly of being inept. These successive and continuous violations of the employees’ self-confidence result in a complete demolition and destruction of the employees’ inner stability and self-esteem, initiating the downward spiral and vicious circle which follows:

Vicious circle

https://static-content.springer.com/image/art%3A10.1186%2Fs41469-017-0015-0/MediaObjects/41469_2017_15_Figa_HTML.gif
The self-esteem-destruction-machinery described caused by the permanent double bind-power games deprives the employees step by step of any mental stability and this increases the risk of them becoming burnt-out and depressed.

Detrimental effects for the organisations’ long-time survival

Traumatised by double bind and deprived of any self-respect and self-esteem the thereby caused auto-aggression is channelled either into psychological, psycho-somatic or physical illnesses. All three reaction channels (physical/psychosomatic/psychological) lead to increasing absenteeism. The result is a know-how and competence drain coupled with shrinking productivity as well as a decrease in quality and efficiency, thereby risking the organisations’ position in the market.
Moreover, double bind-organisations become incapable of learning from their mistakes (Argyris, 1977; Hennestad, 1990) thereby losing their ability to adapt to changing environments.
An organisation which is – due to double bind
  • not productive,
  • not evolving due to the lack of learning and
  • not adapting to changing environments, which has been rendered impossible,
runs the risk of becoming insignificant and obsolete.
The reason for that lies in one of the characteristics of a double bind-organisation, that the occurrence of mistakes is strictly denied and due to this double bind-implemented system of fear, mistakes are not revealed because employees are afraid of first being blamed and later punished for a mistake. A double bind-organisation is thus missing the unique chance of learning from these mistakes, thereby losing the possibility to adapt production chains, procedures or any other vital management decisions in due time; or to fine-tune the company’s steps towards a future and solution-orientated direction. Furthermore, the double bind-organisation is left with employees not daring to mention any improvements, hiding mistakes, being forced to cheat due to the unfeasible double bind-orders and willing to follow each and every insane, unsound and unhealthy path of the double bind-organisation in the end. The ones who have had the chance or the courage to leave will have long left the double bind-organisation to keep healthy and sane. In each of these cases, double bind-organisations lose their employees and, along with them, the necessary know-how for the organisations’ future prosperity.

What can leaders/managers do about that?

Top-level-management has to take responsibility for:
  • an organizational culture and structure which stops tolerating double bind-messages and games of power and control played by those trying to gain personal advantages by doing so
  • implementation of a culture of mutual trust, respect and authentic appreciation
  • an open, transparent, congruent and authentic communication culture in the firm, and
  • an authentic and consistent error-friendly environment.
To fight double bind in organisations and abolish the lack of transparency cultivated in double bind-organisations for the sake of reigning through a system of power and control, an ethos of openness as well as a culture of authentic, double-bind-free communication including encouragement of meta-communication (communication about the communication) is needed. This includes the chance for an employee to name and clarify the double bind-spoiled paradoxes and dilemmas without having to fear consequences. It is even better when the organisational ethos encourages employees to make suggestions for improvements, which are seen by the leaders as an asset to bring the organisation forward. A vital precondition to reach this should be a true and honest attitude of appreciating all staff members for their individual and specific talents and strengths (resource-orientated view with respect to a company’s people), as employees perform best when they can use their individual strengths and resources for their work. There is a need for concrete descriptions of the employees’ tasks, responsibilities and roles within the system, enabling them to have a clear concept of their own role within the organisational system and of their duties due to it. Organisational structures must also stop tolerating unethical behaviour on every company level, including bullying (Boddy, 2011) and toxic leaders that are machiavellistic, narcissistic and psychopathic (dark triad) (Paulhus & Williams, 2002), thereby stopping pathological leaders from doing their toxic work. A double bind-free organization would not confuse a psychopath’s manipulating activities and tactics (by which they make other people abide by their will for only their own prosperity and gain) with “leadership” qualities but would promote self-confident and authentic personalities who have the inner attitude of truly appreciating people and employees.
Another vital step would be the implementation of an ethos of mutual trust, respect and authentic appreciation within the firm which would also ease one of the core dilemmas in double bind-spoiled environments, i. e. the equilibration of the two different interests: autonomy sought by the employee and control preferred by the managers/leaders. One major step to reach this would be to stop ignoring or denying the employees’ know-how and objective opinion (even when it is explicitly requested). Ignoring the employee’s expertise – sometimes even openly and in front of other staff members or clients – leads to a similar self-esteem-destruction as described above.
Employees who are instead treated respectfully, whose individual strengths are seen as a resource and promoted and who are valued for their specific expertise and personal skills stay healthy, well-balanced, motivated and productive due to their higher job satisfaction which strengthens their immunesystem. They also tend to remain in their organisation, providing it with their best possible morale, productivity, performance and OCB (organisational citizenship behaviour) (Van Dick et al. 2006) and help advertise the qualities of their firm (employer branding).
A double bind-free communication would also include consistent orders in case of two or more levels of bosses whose messages have to be consistent in order to avoid being a double bind-paradox. If the order given by boss A is not simultaneously feasible together with the order given by boss B, it will not matter which order the employee chooses to fulfil, he/she will be reprimanded by either boss A or boss B for not having obeyed his/her order correctly.
Maybe the most important step would be to reach an organisational ethos of honest error-friendliness together with a common spirit to bring the organisation forward. This requires a consequent self-scrutiny on all levels of an organisation for which Argyris (1977, 1994) suggests the concept of double-loop-learning which includes questioning of the system itself and the scrutiny of processes, the reasons and motives behind them (Argyris 1994) as well as the staff members’ attitude and behaviour in order to truly improve, change or abolish long-established routines which hinder any cultural and inner organisational changes.
This requires consequent self-reflexion from all staff members of all levels and a culture in which outcomes of this scrutiny are really seen and accepted as an asset and a learning chance – whatever these results might be.

What can employees do about that?

Individual employees should try to
  • name double binds, paradoxes and dilemmas when they occur
  • support any step and behaviour to stop the double bind-communication pattern from further spreading within the organisation
  • nevertheless bear in mind the limits of employees’ possibilities in a double bind-system
The employee confronted with unrealistic double bind-orders would have to mention this impossibility to their managers in order to respectfully alert them to the dilemma caused by the double bind-messages, thereby asking for meta-communication to clarify the matter. The employee could ask politely which part of the messages should be made priority over the other. As naming the paradox in double bind-systems always carries the risk of being accused of being stupid, insubordinate or insane, the employee will need sound self-esteem and courage to do so. It is also vital that the attempt should be carried out with a true and honest respect and appreciation for all members of the organisation. To help the clarification process, face-to-face-communication would always be preferable over e-mails, webinars or other mere technical means and one of the main rules for a double bind-free organisation should be: Talk with each other instead of about each other!
All staff members on each level should therefore train and maintain a neutral attitude towards all their colleagues, supervisors and co-workers. This helps to avoid being dragged into personal power games and being manipulated by toxic leaders using double binds for their personal goals.
However, any cultural change of a firm can only be reached if triggered and supported by the top-level-leaders in charge who implement the change. An individual employee has, therefore, only very limited chances to trigger a change, and only a few more possibilities to support an already triggered change, e. g. by the steps of clarification in due time or the individual attitude of neutral respect.
But even though the individual employee can, indeed, name the double bind in a message, it will always depend on the overall organisational structure and culture whether the employee will be heard or punished, as double bind-organisations carry the burden of asymmetric power due to double bind-communication.
This means that if upper levels of the organisation (intentionally, consciously or unconsciously) carry on with the double bind-system, it will always be the employee who will be demolished first and, presumably, leave the organisation. Although top-level-management may ignore the overall consequence of impeding their company from learning, potentially causing detrimental consequences for themselves as upper management as well as for the prosperity and existence of the company itself, they may only realise these consequences when it will be too late for the entire organisation.

Examples

  • “You can't have your cake and eat it too”.
  • “Wash my fur but don't get me wet.” (German equivalent.)
  • “Please acquire as many new clients as possible for the new product before it is released but make absolutely sure not to reveal any information about the product before it is released on the market.”
  • “Your budget was cut by fifty percent during the last management meeting and two of the specialists working on your team will leave at the end of this month. However, we expect quicker results of an even higher quality than you delivered last time.”
  • “Why do they keep setting impossible budgets then keep telling us we can't do this, we can't do that. They do not let us do business then they want to penalize us for not meeting the budget.”
  • “Please tell the other project members that we cannot afford another year of financial support for this project, even though we contribute the largest portion of the budget, but make absolutely sure that we are not blamed for the fact that the whole project is endangered by our withdrawal from it.”
  • “Do more with less (resources, manpower, time, budget…).”
  • “Our staff are the most valuable asset our firm possess; unfortunately we will have to let go one third of all employees by the end of the year in order to face the current market strains.”
  • “We are a large team, but only individual achievements are rewarded.”
  • “Show initiative, but never dare question, scrutinise or criticise our system.”

Mind the general indication that a message could be spoiled by double bind if it contains a “but” as this normally negates the first message of the sentence

  • “Help your teammates, but you’ll get fired if you do not perform effectively.”
  • “We need help to adapt (to new markets, new products…), but nothing must change.”
  • “Give me a transparent and truthful report, but I want you always to be positive.”
  • “Our product’s quality is the most important asset, but we must make sure to deliver on time even though the product’s quality criteria might not yet be met.
  • “I want you to take risks, but you will be responsible (and fired) when you fail.”
  • “Be innovative, but do not dare to break our rules.”
  • “Contribute your own experience, but everything was already decided upfront by others.”
  • “You are fully responsible for the project, but you are not given any leeway for any decision on your own.”
Argyris (1977) mentions the double bind between the two organisational rules “hide errors” and “reveal errors”. In both cases, the employee runs the risk of punishment – either for not revealing the error if it is discovered later or for revealing it, as this brings the group and the organisation in trouble or it damages “just” him-/herself because of being blamed to name the error and thereby de-mask the superficially intact brilliant surface which has to stay untouched in a double bind-system. In such a system any detection or correction of errors is, according to Argyris (1977), highly unlikely. He also cites a practical case where organisational members just scratched the surface of a problem instead of getting to the bottom of the problem at hand in order to avoid naming their real intentions. A member of this process is cited by Argyris (1977) with the words: “Why don’t they say that they want to control this place?” The answer would be: because the double bind-play’s core purpose is exactly to disguise the root of its one and only reason: to control processes and others to reign over them.
(All readers are very welcome to contribute further examples of double bind-messages experienced by him/her to the e-mail mentioned in the author’s information.)

Conclusions

Being exposed to double bind-messages over a longer period of time, the internalised expectation and fear of being punished for whatever move, action or behaviour the employee shows, puts him/her into a state of constant agitation thereby causing severe mental strain and anxiety leading to physical, psychosomatic and psychological detrimental consequences. In a first stage, employees of double bind-organisations are destroyed by the damaging psychological effects of double bind. As a further consequence, double bind-organisations not only lose their ability to timely adapt to external changes (in double bind-organisations no learning can take place, impeding the assimilation of a company to changing environments) but, even worse, a double bind institution ends up with mere shells of employees being intimidated, hushed up and unproductive. The employees may be present at work but are impeded from doing it properly because they are dealing more with questions of how to survive in a constantly insecure environment, continuously trying to discover the validity of a message or order given to them, fearing to fulfil any part of it in case they have guessed the meaning incorrectly.
Having internalised these double bind-mechanisms perfectly after a while under the double bind-regime, the employees become so intimidated that they will do whatever they are told without contradiction or question regardless of any hint of the real dangers for the organisation. They will have learned that anything else leads to punishment, exclusion or even to expulsion from the system so vital for them to survive (emotionally and financially).
This is one of the reasons why totalitarian systems prefer to dictate through double bind-communication. They first extinguish the intelligentsia living within, as they will be the first ones to question the system. Thus, subordinates are kept downtrodden, silent and willing: more or less for any kind of behaviour.
Those at work willing to keep their own value system are left with only the choice either to leave the system physically (quit) – only to end up presumably in just another double bind-system – or to become ill (physically, mentally, psychosomatically) – leaving the system indirectly and to their own detriment. The lamentably increasing numbers of sudden deaths or suicides in the course of work is “just” a further – but the worst and most radical – form of denying and leaving a system which is unwilling to accept different ideas, learning from mistakes and questioning the day-to-day course of the system.
If an organisation or entity wants a long-term perspective in its specific segment, it should therefore consistently avoid double binds and instead implement authenticity and a culture and climate of error-friendliness – at least in environments where mistakes can be used easily and safely as a learning source avoiding lethal or other inacceptable consequences like in the case of mistakes occurring in nuclear power stations, for example.
Healthy employees in sound companies are motivated and more concentrated during their working time, which is why they perform better. Companies which perform better prosper, and, being known as good employers, helps them to keep their employees as well as enhances their ability to recruit and retain newcomers with a high potential due to a better employer reputation. It is time for a change in the thinking and behaviour patterns in organisations. A different way of thinking in the case of double bind would be the meta-communication (which is – of course – strictly prohibited in any double bind-system) as it would enable people to question the system.
And finally, to elaborate the view even further:
The mere economically driven double bind-society pushed by the forces of globalisation is increasingly producing double bind-organisations, as a double bind-system’s one and only goal is to sustain itself – irrespective of how much damage it does on the way to people, systems, states, environment, nature and the whole earth which is tiny, small and highly fragile within the vast universe.
It is therefore vital to transform the current system of a merely shareholder-“value”-driven economy to a truly value-oriented humanistic approach in organisations and entities. Otherwise the current century is running the risk of trundling towards a society of paradoxes leading to a self-destruction due to their inability to adapt if no change of the framework to transform the system takes place in time.
If people, managers, leaders, systems, organisations and states do not start to finally (re)think and act differently, we all run the risk of losing everything – like a double bind-system which has demolished each of its inhabitants and abolished itself in the end.

Acknowledgements

Many thanks to all people who have helped and supported this publication.

Author’s information

Angelika Kutz LL.M. works as a counsellor, mediator and coach in Hannover, Germany, and is looking for an institution publishing in English to provide her recently published Springer essential titled “Toxic communication as a cause of illness in companies - The double bind-phenomenon – an introduction for leaders, advisors, coaches” in addition to German also in English (www.​mediation-coaching-hannover.​de; for any thoughts or exchange of experiences with the double bind-topic please feel free to contact her under: kontakt [at] coaching-per-mediation.de).

Competing interests

The author declares that there are no competing interests.

Publisher’s Note

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
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Metadata
Title
How to avoid destroying your employees and organisations due to burnouts, braindrain and fading performance? Stop double bind-communication in your organisation!
Publication date
01-12-2017
Published in
Journal of Organization Design / Issue 1/2017
Electronic ISSN: 2245-408X
DOI
https://doi.org/10.1186/s41469-017-0015-0

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