THINGS FALL APART

Some of my interests as a social scientist (turned clinically trained human services provider) revolve around Medical Anthropology, Ethnopsychology, and the provision of Environmental Arts Therapy (or Art Therapy meets Horticultural Therapy) through a prism of critical social theory. Allow me to elaborate.

Western medicine has historically worked under neutral assumptions about therapeutic processes of healing. Remaining oblivious to socio-historical bias engendered in its own purported objective epistemic content, the medical model with which we are most familiar has also been accused of entertaining a similar contextless opacity vis-a-vis the individuals served. Invariably this has traditionally meant a tendency to mistakenly see values for facts.

This two faced and two pronged neutrality/bias dilemma failed to take into account how socio-culturally diverse and historically situated populations (both patients and doctors) view personhood, human development, pain, illness, causality. Treating problems piecemeal in a  biomechanical fashion required that a standardised, decontextualised body submit to treatment.  The medical establishment, operated under a set of specific rules assumed to be neutral and objective, oblivious for the most part that it’s users may have been differently un/responsive for a host of reasons.

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This functional medical model was interrogated in the 1960s with the burgeoning of the medical philosophy debates. By the late 1990s, trends that translated the new rhetoric  began to evolve visibly on two fronts.

First has been the unrelenting march toward holistic global or humanistic medical practice: The individual patient as a whole person rather than a disease handled solely by a specialist of the dysfunctional and rebellious organ. No longer perceived as a neutral template on which to perform acts of healing, today the patient tends to be more and more received by a team of caregivers belonging to several branches of the human services industry. The patient is attended to as a multifaceted person with social workers and psychologists, occupational therapists and recreations therapists on hand alongside doctors and nurses. The doctors have been required to spend more time in the humanities honing their communication skills, bedside manner, and information gathering skills. Storytelling has become important. Moreover, the patient her/himself is requisitioned for this teamwork. The patient has become central in the narrative of his/her own healing journey, an expert of sorts of their own personal expressions of resiliency.

The second interrogation of the functional model has been aided by  seminal north american research on racial, social and ethnic inequalities in health access and health care, as well as satisfaction reports from culturally diverse groups. This research points to imbalances in social capital and has tended to demonstrate that even today, shocking disparities continue to exist (see this recent study) in medical care, in situ.

There has been slow recognition that this evolution away from a biomechanical medical model in favour of a holistic person-centered approach, can not magically mend systemic slights and institution discrimination. After all,  person entered care may veil systemic slights. However, along with the new holistic humanistic paradigm, a new type of skill, a new type of awareness in the human services industries has become necessary. And so the hard work of self reflection in our professions and our own blind spots has become an increasingly valid activity. For example, addressing the difficult and sometimes controversial corners of  medical practice has meant increasingly to endorse multicultural person centered competency in service providers’ training.

This invitation to a close reading of service beneficiaries (and self reading of its providers) is nothing new, in and of itself. Therapists of many stripes have long been versed in the arts of welcoming their patients and clients “meeting them where ever they are”, supervised to attune to issues of transference and countertransference. Taking into account myriad contextual issues, familial, occupational and intra-psychic particularities is the norm in information gathering training and practice. What has changed is the suspicion that our epistemic heritage is not as white as snow and that we can’t simply go on discussing clinical issues and pathologies in colourblind, or rather culture blind fashion. The question remains, to what extent can cultural competency help us operate?

The  ways in which the ever thorny problematic of cultural competency might be wielded is definitely fraught with ambiguities. Where are the limits? What are the dangers of assuming too much in the other direction and making treatment overly-culturally-specific? Does cultural competency include finding new ways to arm potential patients, empowering them with the right to demand fair and humane treatment? Is it enough to be aware of systemic issues such as access to help or self-exclusion? Where is the place of social action or activism? Is it enough to lend a compassionate ear to troubled swaths of the population riddled with sociological pathos? Is it enough to speak their language, literally or metaphorically? How might a therapist work to gain credibility or render her delivery most authentic to a group? These questions are meant to serve as heuristic, something to think through and about, opening up awareness. Their partial merit belongs with the asking. Perfidiously enough, there are no straight and hard answers.

As latecomers, it should come as no surprise that the newer therapeutic kids on the block, adjunctive therapies such as Art therapy and Horticultural therapy have tended to overlook cultural specificity (of both the providers and of the beneficiaries, in both practice and theoretical framework) while busying themselves with creating a space for recognition and professionalisation. On this note, and to its credit, the American Association for Art therapy (but only recently in 2011) has at least revised its standards and ethics chart to include a section on multicultural competency. But what about some of the conceptual underpinnings of Horticultural therapy? As an exemple of a conceptual-semantic knot, the Horticultural Therapy theoretical framework , might be perceived as tending to operate under a fairly ahistorical, acultural and asocial idea of Nature, or natura naturals. And what about biophilia and the people-plant connection? Do these hold as a universal?

IMG_0740Like Illness or Personhood, or understandings of Causality and Control,  Art and Nature are not neutral categories. Neither are they ahistorical or asocial. No metaphors or symbols or cultural objects can make those claims. Gardens, Plants, Labour…these terms  occupy positions in webs of meaning that are culturally salient. We can’t simply assume that plunging our hands into the soil together with a female refugee from Sri Lanka will be uncomplicated.  And yet pedagogical/didactic literature and the primary textbooks, destined as aids in the training of the new Horticultural therapy professionals particularly, eschew discussions on the meaning of the place that “Nature” may occupy in the lives of certain socio-cultural populations benefiting from services. Attention to traceable cultural, historical and sociological specificities that provide meaningful boundaries and narratives about who should do what, under what circumstances, when and to what ends, can not be safely ignored if we wish to engage rather than alienate potential users and beneficiaries.

To the degree that person centered healthcare has evolved in this century as one of the more successful models of treatment in western Medecine –better recovery, better prevention are observed when the person is involved in their own health narrative and locus of control is negotiated and shared rather than externally imposed– these are important considerations. The integrative holistic health model can be observed making inroads and proves recurrently that it is an empirically sound bet. Tending anthropologically or phenomenologically to someone’s mind and spirit (cultural seats) and body (another cultural seat) must accompany the tending of the pathology.

Here in the French republic of universals, where multiculturalism is still a foul sounding word, it is (to say the least) discomforting to discover a lack of reflection on professional practice around such issues precisely. A recent intervention at a national art therapy conference made this excessively clear where a dramatherapist talked about her workshops in a youth home. Her art therapy sessions were dedicated to ideas of selfhood and citizenship:  white masks (referred to as “des masques neutres”) were used with franco-african female adolescents without any discussion on the meaningfulness or appropriateness of the media.  And yet there onscreen, documented in photos, was something entirely disturbing. It was worthy of an invitation to rereading the classic post war peaux noires masques blanches  of Franz Fanon.  Adolescent preoccupation with body image was entirely evaded, the objectives set by the administrators of the home visibly taking precedence over the need for a discussion on identity that might provide a concrete, fun opportunity to bolster self esteem. Instead another instance of privilege and power was created. Upon discussing the issue after her presentation, the therapist recognised the awkwardness, discovering her own so called Neutrality. A neutrality which, in such a case, might better be described as a blind spot, a deep well of insensitivity in a society that is changing and growing more and more diverse against its wishes. It can not help that the old stereotypes die hard,  as this fascinating study on the french imaginaire demonstrates. But we can not afford to ignore them or the implications in terms of transference/counter-transference for example.

My point is merely this: The ways in which we requisition our therapeutic selves and propose group activities might demand profond rethinking based on our audience.  Are they men, women, transgender,  muslims or atheists,  of afro-malian or euro-belgian descent,  inner city expats or suburban immigrants? We must remain equally prepared to dialogue with their culturally inherited expectations and understandings of Art, Nature, Illness  (On this note it helps to remember that our approach is about connection and community, unthreatening and non judgemental activity and safety. The soil, is a mediator. And so  the  focus on asking what kind of group, with what kind of people is entirely primordial.) Clearly, it is not enough for the Horticultural therapist to master theories of human development,  the evolution of a pathology, how Nature imagery affects mental attention or restores mental fatigue.  Along with notions in sociology of class, occupation and circumstance, the culturally salient manufacture of identity and status also merits strong reflective engagement.

Art therapy, and a fortiori Horticultural Therapy,  especially in France, can only be expected to benefit from embracing some of the ground breaking work of its own home grown ethnopsychologists and ethnopsychiatrists of the likes of  Tobie Nathan (inspired as it were by the anthropological work of american Georges Devereux). There are tools worth investigating as demands become more vociferous and as the qualitative double bind that permeates microgressions against women, arabs, blacks, queers, the elderly, refugees, gypsies, transgenders, “mixed race” or bicultural children redefine a post war contemporary french and european society.

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We could also look to research in the fields of Radical or Critical psychology especially, seeking to open up the black box of monolithic cultural  assumptions and giving voice to certain “indigenous knowledge systems” –to use the hard term. To suggest that there is no single narrative, is to understand to what extent enduring specific cultural practices may effect how a person experiences Nature based therapies.

In a similar vein, power, privilege and collective trauma must be addressed (who has a garden? How? Who refuses to garden? Why?) Again, reflection on gender or intersectionality can not be overlooked. Literature that speaks to our understanding of populations based on age or socio-economic background,  type of pathology or goals and outcomes, while standard and necessary for clinical preparation, do not allow for a discussion around a number of other “pre-morbid” factors such as those we still tend to overlook.

Another place well worth spending time is in the shadows of the theoreticians of the field of ecopsychology. Kin to systemic theory, their concern with the human relationship to the environment has prompted a school of thought that extends the boundaries of identity.  Its not just about families, interpersonal relations or communities of culture, but about a vaster network of meaning that operationalises concepts such as  differential spacecollusive madnessworld as self, all theoretical inroads to making the non-human present.  Enter the ecological self, a systems theory based idea that invites us to take seriously the empirical  possibility of an inclusive sense of self that links people and non persons in various ways and to several vocabularies of being. Not only is identity fluid and flexible, articulating around multiple parameters, there are the multifarious apparitions of collective pasts (culture) and geolocalities.

Reconsidering the therapeutic alliance with a better grasp of the stakes may help to further (horticultural therapist inhales here) maximise the benefits of Nature/Art based therapies for certain populations and individuals. Exploring the meaning of the outdoors, dirt, purity, but also division of labour in the garden, understanding the place of art making, crafting or even cooking, is important. These components are most likely to be found in a very astute, well constructed task analysis where we might ask about relevance, prerequisite skills, and knowledge needed to execute a task. After all, framed in an ethnographically minded way, these preliminaries are liable to elicit culturally specific observations.

Given the present context of new arrivals from the Middle east seeking refugee havens in Europe ; given the backdrop of current social unrest that expresses itself through conflicting and diverse identity politics in post-colonial european communities –there is much to reconsider if we wish to be effective communicators and co-gardeners of souls. But that is the subject of another post.

The blog title refers to the book by acclaimed Nigerian author China Achebe. His symbolic torchbearing heiress and our contemporary, Nogozi Achibie, linked above, speaks convincingly of the problem of single narratives. 

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