Allyship/Upstander/Bystander

Starting with a common understanding of key words, phrases, and potentially misunderstood related terms in DEI discussions helps ensure that all participants feel informed and welcome to participate in the discussion. Some terms have multiple definitions provided to help highlight nuances in the definitions.

Bystander: The bystander effect is a phenomenon in which the increased presence of witnesses or "bystanders" during a crisis actually decreases the likelihood that someone will intervene. This is attributed to the assumption by most individuals that someone else will respond, thus justifying their hesitancy or refusal to take action (1).

Upstander: someone with integrity and courage who: 1) recognizes when something is wrong; 2) respectfully intervenes to educate and promote civil and professional conduct; 3) and raises awareness about the behaviors to (hopefully) prevent the situation from happening again (2, 3).

Allyship #1: A lifelong process of building relationships based on trust, consistency, and accountability with marginalized individuals and/or groups of people. Allyship is not self-defined—your work and efforts must be recognized by those you are seeking to ally with (4).

Allyship #2: Allyship is an active, consistent, and arduous practice of unlearning and re-evaluating, in which a person holding systemic power seeks to end oppressions in solidarity with a group of people who are systemically disempowered (5).

This section highlights the definitions of other words that may be used in discussion of this topic. Sometimes these words can be used interchangeably with the terms defined above, and sometimes they may have been used interchangeably historically, but have distinct meanings in DEI conversations that it is helpful to recognize.

For Allies: collaborators, accomplices, and co-conspirators (7).

As many users may have varying amounts of time to present this material, the authors have recommended which resources they would use with different timeframes for the presentation.

1 minute: definitions, with handout on 5 Ds

10-15 minutes: definitions, discussion on handout on Dos and Don’ts of being an Ally, as well as handout on 5 Ds, possibly include one discussion question or one role-playing scenario to prompt reflection.  Close with take home points.

30 minutes: definitions, Dos and Don’ts of Being an Ally Handout, 5 Ds Handout, 1-2 discussion questions or role-playing scenarios

This section provides an overview of this topic so that an educator who is not deeply familiar with it can understand the basic concepts in enough detail to introduce and facilitate a discussion on the topic. This introduction covers the importance of this topic as well as relevant historical background.

The terms Bystander, Upstander and Allyship are all words for which one might be able to infer meaning from common English usage, but these terms also have specific understandings in the Diversity, Equity, and Inclusion (DEI) space, as well as historical roots from sexual assault prevention work.  Familiarity with these meanings is helpful to allow confident communication.  Although these terms have relevance for everyone, they are especially useful when discussing how people who belong to more privileged groups can advocate for a more diverse, equitable, and inclusive work environment and culture.  

Allyship: Allies need to listen. They not only need to allow women and underrepresented minority (URM) voices to be heard, without taking credit for their ideas, but also need to amplify these voices.  Allies should notice and take action to counteract the following common behaviors when women and URM colleagues are speaking: interruptions, ignoring, and appropriating ideas. Many experts in this area feel that this skill set involves approximately 90% listening and 10% action.  The goal with any action taken should be to “re-direct the mic” back to the person who was originally expressing their ideas with the goal of empowering others to speak, rather than trying to speak for them (5, 8).

Successful Allies back up attentive listening with an unwavering confidence in the veracity of statements by those who are discussing their lived experience with being in a less-privileged position. “The experts on any form of oppression are the people most directly affected by it, and their analysis of that always takes precedence over the opinions of people who don’t experience it.” This mindset does not allow for being an Ally only when others meet certain behavioral thresholds that merit support, and cannot be retracted or granted based on any responses from the group that is experiencing discrimination or oppression. Allyship is not a “favor” that is granted; Allies should commit to providing unconditional solidarity.  

Allyship does not require you to give your own opinions, and does not grant access to membership in the community of people with whom you are allying.  You should be a part of any strategic meetings to which you are invited, but should gracefully exit from meetings focused on bonding, venting, and defining shared experiences among members.  Allies should not be leaders of a group to which they do not share identity, but they can help promote and amplify voices of leaders within the group.  Allies should support the group in ways they are asked to do, not those they imagine would be helpful.  

Not only should Allies not lead the groups with which they are allied, but an individual cannot self-identify as an Ally.  This status can only be conferred by others who recognize and appreciate an individual outside their identity group’s consistent work to amplify their voices.  Allyship is not something you can or should strive to put on your CV, but is worth striving for because it improves the culture in which we all live (5).

Allyship benefits everyone.  It leads to higher engagement, increased happiness, improved productivity, a greater sense of belonging, feeling safer, higher retention, reduced stress and career advancement (9).

This article nicely summarizes how to be an ally (7).

Allies are welcome/essential when invited at working/strategizing meetings, but not at affinity groups.  Ideas that allies can consciously pursue in healthcare: 

• Be a listening member of a committee, and contribute to strategies. Example: Introduce the new concept that the DEI committee has decided to pursue, then transfer attention to the main speaker.
• Re-direct conversation back to the main speaker when that person is talked over or ignored
• Mentor and actively sponsor women and URM for responsibilities and high-profile assignments.  
• Include women and URMs in all community-building activities in the workplace.
• Identify and track accountability metrics that support respect and inclusion of underrepresented groups and are consistent with the organization’s mission (10). 
• Don’t hesitate to use internal advocates like Human Resources and office of diversity to get support for underserved groups
• Ask for feedback from individuals from marginalized groups, and if one of those individuals takes the time to give feedback, take it as a gift.  Remember that they are not responsible for giving personalized feedback to every person in the non-marginalized group.
• Making sure that committees, leadership, workgroups, or papers have diverse representation/authorship

While Allyship is the cumulative work of awareness, listening, and everyday decisions on when to speak up or act to support others whose voices otherwise may not be heard, the terms Bystander and Upstander refer to the potential for paralysis and inaction even after an individual has noticed an unjust act occurring in front of them. Upstander/Bystander expresses the duality of options we feel when faced with the individual decision of whether or not to act, and if so, how.  We fall into the Bystander trap of assuming someone else who is more equipped to handle the situation will step up, and that our intervention will not be needed/appreciated, and thus the benefit to others from becoming involved is not worth the potential risks to ourselves.  

Bystanders and Upstanders: Dr Dorothy Edwards pioneered the Green Dot bystander intervention program in 2006 at the University of Kentucky, as a successful measure to help intervene in sexual assaults.  This framework has progressed from the original 3 words (Direct, Distract, Delegate) to involve 4-5 words that begin with D (with some variability and evolution of the specific words) as possible strategies that can help Bystanders intervene and become Upstanders when witnessing injustice. “In 2014, two New Jersey high-school students began a campaign to promote a word, upstander, that gave a name to a behavior that is crucial for building stronger communities and a more humane world.”  They recognized that the term “bystander training” for programs such as the Green Dot, turned bystanders into something that by definition was no longer a bystander, but for which no word existed.  They coined the term Upstander, and lobbied to have it included in the Oxford and Webster dictionaries (11).

The D’s of intervention (12, 13):

• Direct: Can either be a check-in with the victim, or a direct response to the perpetrator
  • Examples of helpful questions - Are you okay? How are you doing? What do you need? Would you like to go?
  • Provide options, a listening ear, and make sure that they get home safely.
  • OR Verbally address the incident and respond to the perpetrator in the moment.
• Distract: Interrupt the situation and decrease risk to individuals by shifting the focus of the perpetrator
• Delegate: Tell another person who can help you intervene (friend, police, someone with authority, etc.).
• Delay: Check in with impacted parties (victim and/or perpetrator) after the incident occurred and continue with follow up.
• Display Discomfort: Express nonverbal concern about what is occurring, as an immediate feedback to the perpetrator

This section highlights the objective data available for this topic, which can be helpful to include to balance qualitative or persuasive analysis or to help define a starting point for discussion.

Some specific statistics regarding allyship are found here:

• Discrimination from families or patients is common, accounting for 22% of discrimination faced by trainees (14).
  
  
• While white employees saw themselves as allies 80% of the time, black women were only perceived to have access to allies approximately 25% of the time.  Only 10 percent of Black women and 19 percent of Latinas say the majority of their strongest allies are white (15). 
  
  
• Specific statistics regarding the effectiveness of allyship/upstander training are limited, especially within Emergency Medicine.  Several programs on Allyship training that have been created and marketed to businesses, as improving diversity and equity, have been shown to improve corporate profits.  Some of these programs show that participants improve their confidence in acting as Allies (14).

Images and graphical representations in presentations can clarify concepts and enhance interest. Please cite the sources of these images appropriately if you use them in your presentation, found in the last section of this page. We purposefully avoided providing complete slide decks in this curriculum, and instead opted to offer easy building blocks for a great personalized presentation regardless of the format.

This is a 1-page handout on the Dos and Don'ts of being an Ally. Although this comes from a sexual assault advocacy group, it is a great concise summary of the pearls and pitfalls of Allyship (5).

Role-playing scenarios can enhance investment and participation. Always consider psychological safety when asking participants to engage in any role-playing activity to avoid potential adverse effects. We highly recommend a discussion for each group to agree on ground rules of respectful learning prior to engaging in any role-playing scenarios (embrace ambiguity, commit to learning together, listen actively, create a brave space, suspend judgment, etc.). It is reasonable to review these ground rules prior to each role-playing discussion.

1. Play out a set scenario that fit 1 of 3 possible discrimination types, (1) discriminatory statement eg, “I’m so glad that you’re a white doctor,” (2) a discriminatory request eg, “Could we have a white doctor please,” or (3) mistaken identity eg, a patient or family member acting like a Black doctor is on the janitorial staff. 
   
   In the case of overt discrimination, a clinician should use “I” statements and make the position clear with a statement like “I’m asking you to not use that language while your child is being treated by our medical staff.” In cases of microaggressions, the clinician should reflect the statement back with an “I” statement such as “What I heard is that you think…” In both cases, the clinician should then move the conversation back to the child’s medical care. Following an encounter, a clinician should tell other colleagues about what occurred and a debriefing should happen (21).
   
   
2. Take the 5Ds response list presented here by Southern Poverty Law Center and brainstorm specific responses that are health-care specific (21). 
   
   
3. Use the study design presented by York et al (12) or just use the case prompts presented in the appendix of this article to prompt discussion of appropriate responses as an ally using the 5D framework.  Here are the case prompts from the appendix: 
   
   Bystander Training Example Cases (12)

This section should help the facilitator anticipate any questions, naysayers, rebuttals, or other feedback they may encounter when presenting the topic and allow preparation with thoughtful responses. Facilitators may experience concerns about their personal ability to present a specific DEI topic (ie a white facilitator presenting on anti-racism or minority tax), and this section may address some of those tensions.

Barriers/Challenges:

• Does stepping in as an ally contribute to silencing the voice of the person for whom you are showing allyship for?  Or demonstrating that you don’t think they can speak for themselves? 
  
  
• What if I do or say the wrong thing? What if, as someone who's never experienced the difficulties conferred by this group identity, I’m not really the right person for this job? A healthcare practitioner's tireless fight for the health and healing of patients is the fight of the ally. As physicians, we bind ourselves together with people who suffer from illnesses that most of us will never experience. For example, one does not have to have had cancer in order to treat and walk alongside someone who does, or to imagine the immense worry created by having to remain ever vigilant for recurrence even after the laboratories and imaging suggest improvement. Even though the prior experience of illness may confer a different kind of connection with patients, not having had cancer does not make the caregiver any less qualified. And although understanding an individual patient's condition is distinct from understanding a group of systematically disadvantaged people, the skills that nurture persistent advocacy for patients can be duly applied. Practitioners of medicine, particularly those belonging to majority groups who are unburdened by the disadvantages conferred by membership in minority groups, are uniquely positioned to serve as allies to patients, colleagues, and communities at the margins (16).

Controversies:

• Ironically, when one recognizes unfairness and strives to address this injustice, it is common for one’s personal or professional position to be advanced. Benefits can include approval from people on the bottom of the coin, acclaim for one’s expertise, awards for advocacy, praise for courage and selflessness (i.e., the courage to talk about issues that others have to live with daily), being hired for health equity positions, or academic promotion based on achievements in advancing health among marginalized groups (17). 
  
  
• “I cannot begin to count how many times I’ve attended public demonstrations and heard people tell themselves that just showing up was an example of them being an ally. Allyship creates a false quantification of deeds rather than self-reflection on intention and approach” (18).
  
  
• Allyship vs solidarity.  This author feels that solidarity is a better concept (18).
  
  
• Is Ally becoming an overused term?  One EM MD-owned group is using ALLY as its brand name.  MD Ally is another branded service focused on EMS/MD communication (19, 20).

This section may be useful to hospital ethics committees who want to increase their DEI awareness as part of monthly meetings, or to other groups who are interested in the ethical underpinnings of the topic.

• Virtue ethics, common good ethics, justice ethics, leadership ethics

Sometimes DEI topics can present depressing history and statistics. This section highlights glimmers of hope for the future: exciting projects, areas of study inspired by the topic, or even ironic twists where progress has emerged or may be anticipated in the future.

Investment in allyship may have more impact than investing in general DEI education, because Allyship by definition requires action, not just thoughts or beliefs. Allyship has to be noticed by others.

A journal club facilitator can access several salient publications on this topic below.  Alternatively, an article can be distributed ahead of a presentation to prompt discussion or to provide a common background of understanding. Descriptions and links to articles are provided.

1. This article offers a good overall summary of issues surrounding Allyship. It is focused on the business world, but offers concise but easily understood explanations of relevant terms, and introduces potential issues when attempted Allyship goes awry. It could serve as a stand alone introduction and prompt good discussion (7).
   
   
2. This is an article in the EM literature about an innovation in which medical students were taught how to use the 5 D framework to go beyond passivity as bystanders when faced with simulated discriminatory scenarios. The appendices from this study are available and include the actual case prompts if others would like to replicate their educational design. The data showed increased confidence from “low” prior to the intervention to “moderate” afterwards, but this continued to increase 8 months later, which may indicate there was a lasting effect from the intervention and even subsequent growth after real-life practice (12).

The questions below could start a meaningful discussion in a group of EM physicians on this topic. Consider brainstorming follow-up questions as well.

1. What are the barriers you have encountered to being an Upstander? 
   
   
2. What do you perceive as the risks of acting to stand up in support of someone else who does not share your identity groups?
   
   
3. What concrete ways can we brainstorm to make changes in our group to promote Allyship?

The authors summarize their key points for this topic below. This could be useful to create a presentation closing.

1. An Ally works to understand and mitigate individual and systemic biases despite not being a person who is directly negatively affected by them. An Ally does this by listening to less privileged voices, trusting them to be experts on and to know the truth of their own experience, and amplifying their voices.  An Ally does this because the world is better for everyone when diverse voices are heard, not for any personal gain or to assuage personal guilt or to deflect personal responsibility.
   
   
2. The 5Ds (Direct, Distract, Delegate, Delay, Display Discomfort) offer a framework to help “unfreeze” and take action when you notice discrimination or harrassment.  These techniques must be practiced, and different strategies may work well for different people and different situations.  
   
   
3. There is no such thing as a “neutral” bystander.  If you see injustice and allow it to occur unchecked, you are perpetuating it.  Even if you don’t feel safe directly confronting the perpetrator, you have other options to intervene.

Meaningful and relevant quotations (appropriately attributed) can be used to enhance presentations on this topic.

• “In the end, we will remember not the words of our enemies, but the silence of our friends” –Martin Luther King Jr 
  
  
• “If a Black person tells you that they’re feeling something is racist, just believe them.”— Wilda White, a consultant in Poultney, Vt. 
  
  
• “We know allyship is a huge lever in creating change. It isn’t a ‘check the box.’ It’s a behavior. It’s something we have to sustain.” –Lindsay-Rae McIntyre, chief diversity officer at Microsoft (23).
  
  
• “One of the less dismaying aspects of race relations in the United States is that their improvement is not a matter of a few people having a great deal of courage. It is a matter of a great many people having just a little courage.” –American novelist Margaret Halsey, 1946 (24).

Below are links to Emergency Medicine-specific resources for this topic. 

1. Allyship in Residency: An Introductory Module on Medical Allyship for Graduate Medical Trainees (25). A publication describing a 1-hour educational intervention teaching allyship to EM residents, showing improved topic knowledge and comprehension of allyship competencies.
   
   
2. Allyship Behaviors for Gender Bias in the ED (26). EM-specific prompts that might be used as allies to women in EM respond to common microaggressions in the ED. Tip sheet also included.
   
   
3. Dr. Colleen Sweeney, on EM Pulse Podcast. 20 minute video lecture at UC Davis School of Medicine, speaking about taking allyship to the next level (27).

Below is a link to an educational resource or supportive program in the community that is working on this topic. 

Southern Poverty Law Center: brief handout on bystanders' progression to upstanders.  It uses the 5D framework, but lists “Document” as the final D (22).

Below are links to videos that do an excellent job of explaining or discussing this topic. Short clips could be used during a presentation to spark discussion, or links can be assigned as pre-work or sent out for further reflection after a presentation.

Allyship for the EM Resident: A Clarion Call to Action (28).
This is a 5 minute summary of Allyship in EM, presented at SAEM IGNITE! 2021

Possible questions and an answer key are provided below. These can be useful to document effectiveness in learning and knowledge gained but can also be useful to help learners identify that they may not actually know everything about a DEI topic, even if they have participated in presentations on it previously.

1. Being an Ally means you aren’t racist or biased T/F
   
   
2. When witnessing harassment, it is obvious who is a bystander and who is an upstander T/F
   
   
3. Write in the 5 Ds used in the framework to be an Upstander when witnessing discrimination or harrassment. 

Below is a statement that inspires participants to commit to meaningful action related to this topic in their own lives. This could be used to prompt reflection, discussion, or could be used in a presentation closing.

Are you willing to commit to taking action toward becoming an upstander instead of a bystander?  Has this discussion prompted ideas of how you could work towards allyship with a specific group in your work environment? What commitment can you make that you will act on this month?  How will you remind yourself to follow through on that commitment?  (Text self, make calendar appointment to reflect once per week, etc)

All references mentioned in the above sections are cited sequentially here.

1. Grace Poon Ghaffari, Stanford Share: Education Team.  Upstander Intervention, Accessed here: https://sara.stanford.edu/upstanderlife
2. IDEAs in Action, Berkeley Lab.  Accessed here: https://ideas-in-action.lbl.gov/accountability/upstander
3. Meredith Moore, Upstanding Allies in Diversity: Taking its inclusive approach to new heights, Weil actively engages employees – and clients – in its program’s efforts. In-House Ops: Leading the high performance law department. Posted on November 18, 2016. Accessed here: https://www.inhouseops.com/2016/11/upstanding-allies-diversity-taking-inclusive-approach-new-heights-weil-actively-engages-employees-clients-programs-efforts/
4. Blog by Ethical Leader. Be an Upstander, not a Bystander: Inclusive Allyship June 14, 2020, accessed here: https://ethical-leader.blog/2020/06/14/be-an-upstander-not-a-bystander-inclusive-allyship/
5. Working Definition of Allyship: The Handout.  Oregon Coalition Agaist Sexual Violence uploaded Jan 10 2015, accessed here: https://www.ocadsv.org/sites/default/files/resource_pub/allyshipdefinition_handout.pdf 
6. Samantha-Rae Dickenson. What is Allyship? National Institutes of Health EDI stories, January 28, 2021, accessed here: https://www.edi.nih.gov/blog/communities/what-allyship 
7. Tsedale M. Melaku,Angie Beeman, David G. Smith, and W. Brad Johnson. Be a better ally. Harvard Business Review Magazine Nov-Dec 2020.  Accessed here: https://hbr.org/2020/11/be-a-better-ally
8. Rangita de Silva de Alwis.  Allyship: Upstander vs. Bystander. September 17, 2020  Accessed here: https://www.law.upenn.edu/live/news/10473-allyship-upstander-vs-bystander 
9. Shelley Zalis. Why Allyship Is Good For Business.  Forbes.com Nov 10, 2021, accessed here: https://www.forbes.com/sites/shelleyzalis/2021/11/10/why-allyship-is-good-for-business/?sh=73c27e4b1a45 
10. Ann Skeet. The Ethical Ally.  The Markkula Center for Applied Ethics, Santa Clara University Jun 10, 2019, Accessed here: https://www.scu.edu/ethics/leadership-ethics-blog/the-ethical-ally/
11. Facing History and Ourselves. What difference can a word make? Holocaust and human behavior.  Chapter 12.  Accessed here: https://www.facinghistory.org/holocaust-and-human-behavior/chapter-12/what-difference-can-word-make
12. Michelle York, Kyle Langford, Mario Davidson, PhD, Celeste Hemingway, MD, Regina Russell, PhD, Maya Neeley, MD, Amy Fleming, MD, MHPE.  Becoming Active Bystanders and Advocates: Teaching Medical Students to Respond to Bias in the Clinical Setting.  Med Ed Portal August 19, 2021  https://doi.org/10.15766/mep_2374-8265.11175 
13. An Overview of the Green Dot Strategy." California Coalition Against Sexual Assault (CALCASA). California Coalition Against Sexual Assault. Web. http://www.calcasa.org/wp-content/uploads/2011/04/Curriculum-Summary.pdf
14. Rahiem ST. Moving from bystand to upstander: responding to discrimination from patients/families. Pediatric Academic Societies Meeting 2021; May 1, 2021; virtual. Accessed May 1, 2021. Available here: https://www.contemporarypediatrics.com/view/using-an-algorithm-to-be-an-upstander-in-the-face-of-discrimination 
15. Women in the Workplace Survey 2020.  Survey of more than 600 companies by McKinsey and Lean In. Page 30. accessed here: https://wiw-report.s3.amazonaws.com/Women_in_the_Workplace_2020.pdf and here: https://leanin.org/allyship-at-work 
16. Ellis, Danielle.  Bound Together: Allyship in the Art of Medicine.  Annals of Surgery: August 2021 - Volume 274 - Issue 2 - p e187-e188
17. Nixon SA. The coin model of privilege and critical allyship: implications for health. BMC Public Health. 2019;19(1):1637. Published 2019 Dec 5. doi:10.1186/s12889-019-7884-9
18. Owens,Earnest. OPINION: Why I’m Giving Up on “Allies”.  Philadelphia Magazine, City Life June 23, 2017.  Accessed here:https://www.phillymag.com/news/2017/06/23/allyship-vs-solidarity/
19. Media release accessed here: https://www.prweb.com/releases/usa_emergency_centers_launches_ally_medical_emergency_room_aligned_with_its_patient_first_philosophy/prweb17684443.htm
20. Commercial website accessed here: https://www.mdally.com/
21. Miranda Hester. Using an algorithm to be an upstander in the face of discrimination.  Contemporary Pediatrics. May 1, 2021.  Accessed at: https://www.contemporarypediatrics.com/view/using-an-algorithm-to-be-an-upstander-in-the-face-of-discrimination 
22. Southern Poverty Law Center Campus Guide to Bystander Intervention.  October 05, 2017.  Accessed at:https://www.splcenter.org/20171005/splc-campus-guide-bystander-intervention 
23. Patrick Thomas. What Does Being an Ally Look Like?  Companies Offer Training in Support of Black Colleagues.  The Wall Street Journal. July 12, 2020. Accessed at: https://www.wsj.com/articles/what-does-being-an-ally-look-like-companies-offer-training-in-support-of-black-colleagues-11594602000
24. Alexander M. Czopp, Margo J. Monteith & Aimee Y. Mark, Standing Up for a Change: Reducing Bias Through Interpersonal Confrontation, 90 J.PERSONALITY & SOC.PSYCHOL. 784, 791 (2006).  
25. Martinez S, Araj J, Reid S, Rodriguez J, Nguyen M, Pinto DB, Young PY, Ivey A, Webber A, Mason H. Allyship in Residency: An Introductory Module on Medical Allyship for Graduate Medical Trainees. MedEdPORTAL. 2021 Dec 20;17:11200. doi: 10.15766/mep_2374-8265.11200. PMID: 34988287; PMCID: PMC8685188 https://www.mededportal.org/doi/10.15766/mep_2374-8265.11200
26. Stavely, T.  Allyship Behaviors for Gender Bias in the ED. Emory Department of Emergency Medicine.  pdf accessed here: https://pubmed.ncbi.nlm.nih.gov/34988287/
27. Medeiros, S and Sweeney, C on EM Pulse Podcast. UC DAvis EM.  July 17, 2020.  Accessed here: https://ucdavisem.com/2020/07/17/from-ally-to-advocate/ 
28. Monica Saxena.  Allyship for the Emergency Medicine Resident: A Clarion Call to Action.  Presented at SAEM 2021 May 12, 2021.  Video accessed here: https://www.youtube.com/watch?v=ERSlAd9bxY8