'Diagnosis determines intervention.'
There’s a very big difference between ‘What’s wrong with you?’ and ‘What’s happened to you?’ Jo Watson’s book, Drop the Disorder (2019) is a timely and courageous personal-professional challenge to the creeping influence of the biomedical model into social-psychological therapeutic thinking and practice. In her aptly titled article in the book, ‘There’s an intruder in our house!’, she reflects with a pained air of near-despair on this gradual, alarming and depressing diagnostic drift:
‘It wasn’t always like this. I joined a profession that held a shared belief about the nature of human emotional distress. We understood that the many forms of human suffering we witnessed – ranging from feeling low and suicidal to self-injury, hearing voices, overwhelming anxiety and dissociative experiences – were responses and reactions to what had happened in people’s lives and, in many cases, the resourceful and creative coping strategies they had developed to survive.
We clearly and consistently made links between emotional distress and causal factors like poverty, racism and abuse. There was a deep, collective ‘knowing’ that social circumstances were linked directly to human suffering and this acknowledgement translated into a connection with the political arena. Yet, as I write, this work has been consumed by a biomedical monster that has crept into our house and made itself very much at home. In fact, I don’t feel this is my home anymore.’
Jo is challenging a fundamental risk of the biomedical therapeutic model, that it locates a perceived problem in an individual, irrespective of a broader context. In doing so, Jo echoes disaster management expert Marcus Oxley’s insight (in a different arena) that, if we see a pattern of symptoms in people attending an Accident & Emergency unit, it may well reveal something implicitly about conditions in that context. It’s always about the person, but it’s rarely only about the person.
Have you eaten?
In my first encounters with the Philippines, I was surprised by how often people asked me about my meals. ‘Have you eaten?’ This included during conversations online. I learned, over time, that the question arises out of an economic context in which food is often scarce owing to high levels of poverty, and a cultural context in which the health and well-being of one’s neighbour is considered important. It means the question is literal and it calls for a literal response. If I answer ‘no’ while I’m there physically, I’m likely to be offered and given a meal; even if the person who’s asking is poor.
Rudo Kwaramba, a Zimbabwean colleague, explained a similar dynamic whilst working together on an assignment in Uganda. I had been invited there to help an NGO address a key challenge: that managers in rural community-based projects were, apparently, bad at addressing poor performance. Rudo reflected: ‘In wealthy countries, if you can’t earn an income or lose your job, your government provides you with financial support; if you become injured or unwell, your health system or insurance covers you. In poorer countries, people can only look to each other for support.’
It means that, in such contexts, to establish and maintain positive relationships with one’s extended family and neighbours is essential for survival. It also means that to support the health and wellbeing of one’s neighbours is critical too. There is a sense of radical interdependence, a pragmatic-ethical need, that drives cultural behaviour. Against that backdrop, we discovered that managers who were living and working in the same communities as their staff felt unwilling and unable to address poor performance – in case it damaged the network of relationships. It was the core issue for them.
This insight moved the culture-shift question in the work from a simplistic-transactional, ‘How to change the performance management system’, to a deeper-relational, ‘How can we hold honest conversations that don’t harm community?’. It proved transformational. As I focus back on South East Asia, I notice that as some countries have grown in wealth, they have experienced a corresponding shift towards individual-orientated cultures. It's as if: the richer I am, the less I need you. ‘Have you eaten?’ is often retained, yet as a simple greeting, not as a literal inquiry or as an invitation to a meal.
So, I’m curious: what have been your experiences of working cross-culturally? What have you learned?
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