Rev. Canon Dr. Nigel Rooms; Diocese of Southwell and Nottingham, UKl Peter Bates; National Development Team for Inclusion, UK
For further information, please contract Peter Bates at email@example.com
Since the late 1990s, the European Community has shared a concern about social exclusion which has been applied to English mental health services since 2004. Compared to the general population, people with severe and long-term mental health difficulties are less likely to be employed or engaged in lifelong learning, less likely to live in stable accommodation and less likely to have a rich network of friendships and leisure activities. Reasons for this are complex and include the damaging impact of mental ill health, the discriminating attitudes and behaviour of the general public and the segregating manner in which mental health services have been delivered (SEU, 2004).
In recognition of this problem, staff working in mental health services are now expected to develop their skills in promoting opportunities for their service users to live an included life (NSIP, 2007). Whilst this is a process fraught with dangers, not least of coercing service users into a prescribed lifestyle or pushing intolerant behaviour underground, there is no doubt that progress can be made by supporting individuals to find, get and keep the life they want in the wider community, rather than merely offering medication and support within the sanctuary of traditional mental health provision.
Promoting socially inclusive activities will place mental health staff at community interstices the places where different cultures within the larger society meet and overlap. We are interested in both the place where the mental health culture meets various segments of community (employment, education, sports and so on) and where these different segments meet one another. Some mental health staff is specialising in this interstitial role and carry job titles such as Community Bridge-Builder or Community Access Worker. Understanding what happens when cultures meet is therefore a key competence for these staff.
The first author is an ordained minister in the Church of England who spent seven years working cross-culturally in Tanzania in the 1990s. On returning to England he completed doctoral research on the integration of faith and culture through adult theological education (Rooms, 2008). The second author consults to mental health organisations, specifically assisting them to develop socially inclusive practice. After observing that a great deal of social inclusion work is coloured by cultural factors, he used an internet search engine to find someone who might understand more about this topic, and this paper is a result of the ensuing discussions. Readers may wish to note that it is not necessary to have sympathy with the theological ideas harnessed in this paper in order to utilise its analysis.
Bridges between cultures
The second author arranged a training event recently for a team of Community Bridge Builders in which they invited some community representatives to meet with them and talk about the opportunities for participation. Amongst others, a Church of England minister took up the invitation. He began by saying that he felt some affinity with the mental health workers, as his title of priest meant bridge builder between God and humanity and between different communities. This was a formative moment for that staff team.
In order to learn more about Community Bridge-building, we wish to utilise some analysis undertaken by theologians who have explored the Christian concept of cross-cultural mission. Whilst the Christian missionary is often portrayed as a figure of fun in our postmodern society, the honesty and rigour of contemporary theological analysis has much to teach.
Indeed, theological reflection has been applied to many areas of mental health care, including the very existence of mental illness, specific illness experiences such as depression, the nature of the caring relationship, the experience of suffering, the place of citizenship and community responses (Coyte et al., 2007; Swinton, 2000). In addition, Depression Anonymous has utilised the 12-step programme developed by Alcoholics Anonymous (see http://www.depressedanon.com/steps.html accessed 7/4/08). In this paper, we suggest that theological reflection on cross-cultural mission also provides a useful lens through which to view the task of these mental health staff.
Crossing cultural boundaries
Cross-cultural issues can be found in many places in our increasingly globalised, yet fragmented world. For example, Robb and Gilbert (2007) vividly illustrate the culture shock experienced in making a transition from working for a local authority to working for the NHS, despite remaining within the mental health sector. There is some analytical merit in simplifying our complex, fragmented world where many subcultures and competing messages vie for influence and assuming for a moment that there are single, homogenous cultures with a clear interface across which simple and clearly recognisable messages pass. Once the issues are elucidated, it may be possible to restore sophistication to the approach in order to more closely reflect the complexity of the real world. This paper will focus upon cross-cultural issues as experienced by Community Bridge Builders in attempting to straddle the worlds of mental health and commercial employment. We begin with a short dictionary of sociological and theological concepts which are discernible when two cultures meet.
Enculturation is the process by which children are socialised within a culture to learn its language of words, symbols and references and to obey its norms. It is both deliberate and unconscious. This is generally a helpful process, unless consent is lacking, when it can become a form of indoctrination.
Translation is the process by which the core message from one culture is explained and delivered in the language of a new culture. This helps people understand the message of another culture, as when a classic text is translated to reach a new audience. Because language and culture are so closely related, the translation can attend to some cultural and socio-economic issues and paraphrase the original meaning where literal word-for-word translation would obscure the original meaning. Nevertheless we might expect the core message to be subtly transformed through the translation process (Sanneh, 1989). Thus the concept of translation presses us to focus on the specific message that one wants to translate, and on the assumption that there are cross-cultural universals that enable the translator to locate cultural equivalents (which are not necessarily exact literal equivalents) in the two cultures.
Acculturation is the process by which both cultures are changed when they meet. Formally powerful and informally dominant aspects inevitably win. The things that survive may not be the best elements of either society.
Syncretism is the fusing of different beliefs and practices. This term is often used where someone considers that one or both original cultures have lost their central identity.
Colonisation occurs through the creation of island outposts by the dominant culture or the appropriation and denigration of host cultures and people. Where the island outposts aim to have little or no impact on the host community this is reminiscent in political history of the principle of Westphalian Sovereignty and in fiction of Star Treks prime directive (Wikipedia, 2008). When used destructively, colonies may infiltrate subversive militants in order to overthrow the original culture, leading to colonialism (in which the outpost raids resources or takes over) and ethnic cleansing, where a culture or even its people are wilfully destroyed. If these attempts fail, then the island outposts may be tolerated, remaining almost irrelevant to the host community, or may attract anger and rejection.
Inculturation is an ongoing, incomplete dialogue between the insider and outsider, the place where pilgrims indigenise and culture changes through a process of mutual correction and adjustment. Dialogue helps both sides to identify, re-appropriate and celebrate their core beliefs and practices whilst learning from and incorporating new elements or developments from the other. Both are transformed. In the host culture the process produces rooted novelty - something that is recognisable as authentic and has integrity but that has not existed before.
Culture and Message
Several of the processes described above hinted at a possible distinction between culture and message. In reality, these may be almost indistinguishable, since the implicit priorities and values that form the culture may simply need to be verbalised and prioritised over other themes to become the message that is evangelically promoted across the cultural boundary. Indeed, it is perhaps when the culture and the message are confused that the host culture adopts trivial cultural elements - one might think of the way English colonialists exported their habit of drinking afternoon tea - rather than the intended message of democracy, education or Christianity. Whilst in the final analysis the line between culture and message may be difficult to draw, it assists our thinking.
Thus, in the interface between mental health services and the world of employment, we might represent the mental health culture as favouring caring and the mental health message as equal opportunities for service users, in contrast to the commercial culture that favours productivity and the commercial message as income generation. These assertions may easily be replaced or enriched without damaging the argument.
Culture and message are brought together in Bevanss (2002) continuum of culture and gospel (which updates the rather static approach from the 1950s of Niebuhrs classic Christ and Culture). Different models are placed along the continuum depending on whether they privilege culture or gospel or neither. There are four main models (outlined below) that start with privileging gospel and move along the continuum towards privileging culture. In each case the privileged item does not eradicate the other, but rather is emphasised over it.
This option privileges gospel as the new arrivals see themselves as different and standing apart from the host culture. It may abandon dialogue and reduce its role to merely demonstrating an alternative culture and lifestyle. There may be aspects of the host culture which are deemed incompatible with the gospel and so evoke opposition from the countercultural community who may seek to radically transform the host society through colonisation or cleansing.
Proponents hold tightly to their understanding of the core, non-negotiable elements of their gospel, but there is a strong focus on explaining it in the language (words, images, symbols, references) of the host culture. Bevans calls this the translation model, but we wanted to distinguish it from the approach we describe as translation above. The core message is rarely changed overtly by this process. Adaptation can take place at various levels (some of which may affect the core message more than others). In Shakespeares Romeo and Juliet the English text can be translated into Italian, adapted in a relocation to 1920s Chicago, or reinvented as West Side Story.
Proponents of this approach are concerned about some pre-defined issues that are assumed to trouble the host community - experiences of poverty, sexism and racism and then they explore how their core gospel can, in a culturally relevant manner, reduce injustice and inequality in the host community. So the local expression of injustice will vary from place to place, as will the specific solution recommended by the newcomers, but the framework of justice, equality and compassionate intervention is non-negotiable.
This approach privileges culture by starting with the belief that the host culture is basically good and has many rich insights to impart. Its own solutions need to be recognised and respected first, and caution is needed in offering a solution to a problem that the community may not recognise as such. The gospel is entirely reframed in the context of this culture.
Cross-cultural Work as Incarnation
How might this apply to the social inclusion role of mental health workers? We must begin by identifying the cross-cultural work with which they are engaged. One approach used by a number of mental health services views the wider society as a number of life domains (Scottish Government, 2007), each of which carries its own values, language, infrastructural and organisational arrangements its own culture. Life domains are not entirely closed concepts but rather loosely cluster a broad group of neighbouring entities under the headings of employment, volunteering, lifelong learning, sports, faith and meaning, local neighbourhoods or the arts. Mental health workers then specialise in building alliances and pathways from the mental health community into one of these segments of the mainstream community. They are therefore navigating the place where cultures meet.
The Christian theological concept of incarnation provides one example of how to navigate this interface. God was at home in the heavenly world, but came to live on earth as a human being: Jesus Christ. God crossed from one kind of world to another, becoming incarnate, enfleshed or embodied in this world at a particular moment and place. For God, being subject to this world as a human agent, meant submission to all that it means to be human, including death.
An incarnational strategy therefore demands a serious commitment. It is not sufficient to merely make a phone call or hold a meeting in the other world. The archetypal Christian missionary went to live amongst the community they aimed to serve; learnt their language, ate their food and wore their clothes. Today the Church of Englands professionals its priests, are still required to live in the geographical communities they serve. In some inner city and outer estate contexts they are often the only resident professionals left.
Mental health workers who navigate cultural boundaries often work with life domains rather than parishes, but can hold incarnational values in their work (while retaining necessary boundaries between their private and public roles). This might require them to obtain a desk or an office base at the Jobcentre Plus office, the college or the community centre. Their coffee breaks and informal relaxation time needs to be amongst the people who inhabit the life domain, rather than back with their mental health colleagues. In this way they will find that the public/private compartmentalisation breaking down from time to time.
There is a real danger of the outposted worker slipping from the genuine dialogue of inculturation into one of the alternatives listed above. For example, in learning the culture of the new setting (enculturation), the worker could abandon the values of the mental health service from which they came some would call this effect rather disparagingly going native. Or in holding strongly to the mental health values, the worker could alienate their new neighbours in the new setting and the resulting anger could lead to the formation of a defensive colony.
Since the people that mental health workers support often want to build connections with more than one domain, individual bridge-builders need to collaborate with one another to ensure that the person receives a seamless and holistic package of support. When facing the community, they often find activities that straddle two or more domains (such as the badminton class in the church hall) and so must work flexibly with the framework. Nevertheless, inhabiting an individual domain allows the worker to specialise, build up expertise in relation to that domain, learn the culture and assist the organisations and networks within the domain to provide a more respectful welcome to people who need additional support.
Advanced bridge-builders also discern the potential for connections, synergies and creative dialogues between one domain and another, as well as between the mental health community and the other domains. Thus they become what John Hull, the former Professor of Education at Birmingham University, calls trans-world professionals who are skilled at negotiating different worlds.
Mental Health and Employment
Improving opportunities for people with mental health problems to get and keep paid work is a priority for mental health services and their partner agencies. So how would this look if viewed as a cross-cultural activity? The earlier dictionary of terms can be brought to bear on the task, working Bevans observations on culture and message into the definitions as we go. We have tested this out by viewing the mental health culture as the new arrival and the employment domain as the host community and looking for the different organisational structures that arise in response to each approach. Subsequently we need to explore how each of these methods of working might affect the face-to-face work carried out by bridge-builders.
This process happens to all new employees under the banner of job induction and includes the formal and informal learning that happens about how things are done in this workplace. New employees who choose to hide their mental health difficulties learn the ropes through this process alone. It is a natural process that is always happening but can and perhaps needs to be deliberately encouraged if people who need additional support are to gain full access. However, if it is all that happens, the bridge back to the mental health world can fall, with the danger, as noted above, of going native.
Mental health promotion workers are joining forces with the Health and Safety Executive to present their message about mental health to employers. As a positive step, they are taking the mental health gospel out from the health service to the world of employment. But what is this message? We mentioned earlier that there are in fact many competing subcultures and many competing messages. Indeed, some of the internal conflict within mental health services may be attributed to the different understandings that simultaneously exist about the nature of the mental health gospel.
There are also signs of some messages being lost in translation or distorted en route. Rather than suggesting that people with severe mental health problems deserve fair and equal opportunities (arguably the original message), they are seeking to show how a mentally healthy workplace is good for everyones productivity, safety and morale. Thus the emphasis shifts from obtaining job opportunities for people with severe mental health difficulties to securing good mental health for the whole workforce. As a result, large employers are introducing a gym or healthy food at the canteen (undoubtedly good for everyones mental health) but may have made no progress in offering a job to someone who has been hospitalised for schizophrenia.
Thus translation slips into syncretism (of which more below) as this initiative blends the concern about people that originates in the mental health service with a concern about productivity that originates in the business community. In doing so it has shifted the focus away from people who would be entitled to specialist mental health care, as it is essentially about wellness, while the mental health service is about illness. Moreover, the new message has failed to contextualise the message that people with serious mental health problems can recover their life in the community. It comes as no surprise, then, that in Scotland, which has invested heavily in presenting this syncretistic message for employers, public attitudes to common mental health problems (such as minor depression or anxiety treated by the GP) are improving whilst attitudes towards people with a diagnosis of schizophrenia are hardening.
What is required then on the part of the translator of the message are key skills accompanied by assertiveness in making the message audible and credible in the work culture while not losing its integrity and foundation. We return to this theme when discussing inculturation below.
The governments drive to reduce the number of incapacity benefit claimants by 30% is driving mental health services and employers into the same space. This clash of cultures leads to some elements winning, such as the JobCentre Plus pre-occupation with unemployed people who are deemed to be close to employment rather than helping the most disabled people to be more productive or employers to offer new forms of work. Meanwhile, some mental health workers simply deny that the clash of cultures is taking place at all and maintain their hopeless and pessimistic view of employment prospects for people with mental health issues (service users are incapable and unmotivated, would be financially worse off and oppressed by bullying managers and dangerous work) rather than adopting an anthropological or incarnational approach. It is tempting for the mental health worker to refuse the challenge of incarnation and remain in their own world.
We showed above how one attempt to translate has fallen into syncretism at the level of public attitudes. A further expression of syncretism can be found in the development of new organisational forms such as Social Firms. Many of these aim to simultaneously address the mental health needs of their employees whilst meeting commercial objectives, but end up providing neither skilled mental health care nor meaningful open employment. The worlds of mental health and employment are being merged at the cost of a loss of both souls. This is falsely presented as counter-cultural as participants believe that they are demonstrating a way to blend care and work that should be an exemplar to all.
Finding friendly employers and training co-workers in Mental Health First Aid may be seen as colonisation, as line managers become volunteer health and social workers by undertaking surveillance duties and reporting back to the system. Effort is expended on parading exemplar individuals and firms as a counter-cultural demonstration, whilst the remaining companies within the domain are largely abandoned.
A genuine dialogue about the realities of employing people with mental health difficulties in which both the productivity requirements and support needs of the employee are taken seriously and both the mental health system and the workplace are gradually transformed by the ongoing dialogue. This dialogue would mean that the mental health system learns about the business culture while the workplace learns about good support.
The Mindful Employer programme, accessed at: http://www.mindfulemployer.net/ , is perhaps one demonstration of this process. It brings together business culture the harsh realities of productivity requirements, budgets and censure should things go wrong with the compassion and recovery ethos of the mental health service culture. The rigorous dialogue that ensues has all the potential for genuine inculturation and simultaneously bears the risks that it will fall into a lesser form. Over 300,000 people in the UK now work in one of 230 Mindful Employer companies that have chosen to take a positive stance on mental health in the workplace. These businesses are actively look for solutions that reduce stress-related sickness absence and turnover, assist employees who have mental health difficulties and improve links between the world of employment and mental health services, whilst seeking commercial success.
There is much to learn about how mental health workers can develop their skills in assisting people to navigate between cultures, and also much to learn about how mental health services can stimulate the development of structures that facilitate ongoing dialogue and true inculturation. We conclude with a handful of questions that we hope will stimulate further reflection on this important and complex theme.
What is the boundary between cultures that you are seeking to cross?
How do newcomers learn the culture of this new place?
What is the message that you want to take into the new culture?
How much of the message is negotiable?
Which traits of the new culture do you admire and which would you like to adopt?
Where will the long, honest conversation take place between you and people from the new culture that might change you both?
Writing this article has been a fascinating collaboration for us both as we have been attempting to straddle our own two worlds in the process. What has been interesting in finding a publisher for it is the receptivity of the possibility of bringing the two worlds together, particularly in the more secular mental health world. Overall the article raises the question for that world of whether there is a secular sociology that pays equal attention to: (a) culture, and (b) message.
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