It’s our lifestyles that are the problem. Our habits are making us sick. Our cultural norms are fuelling the rise in chronic conditions. The solution is simple: we have to change our culture.
We’ve all heard versions of this message but its alleged simplicity is also its absurdity. What is culture? Where does it come from? And how does it change?
I’ve heard it said that our culture resides in the stories we tell. Although I can understand that, I have always struggled to see it as a target for intervention. And yet, if culture really is at the heart of what’s making us sick, we have no choice but to explore it as an option. The question is, how?
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Luckily someone is trying to answer that. Andres Marquez-Lara is making his life’s work all about how we can use stories, and their performance, to help us see cultural norms, develop greater empathy for them, and then perhaps – just perhaps – discover new approaches for the increasingly-ineffectual world of public health. I was lucky enough to meet him, and even luckier that he allowed me to ask him some questions.
Pritpal S Tamber: Hi Andres. We’ll get to stories and performance in a minute; let’s start with your résumé. From clinical psychology to community psychology, with a stint in quality improvement along the way; what a journey! Let’s start with the basics: what’s the difference clinical psychology and community psychology?
Andres Marquez-Lara: Clinical psychology is a problem-focused approach that assumes that if we have enough knowledge about what causes our behaviour we will have a better chance of changing and relieving our distress. It focuses on the problems we currently face, and therapy sessions take place in dispassionate offices removed from the context of our day-to-day lives. Community psychology, by contrast, is a strength-based approach that works with individuals and communities within their context focusing on the needs they feel are most relevant for them to address, while also focusing on prevention. With 60% of our health outcomes being determined by our social and environmental factors, community psychology’s perspective attempts to address a wider range of variables than clinical psychology.
PST: Explain ‘strength-based’ perhaps by explaining how community psychology is delivered.
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AML: Community psychology builds on the communities’ strengths to help increase the capacity of the community to address the issues they face. It sees community stakeholders as partners in research, and looks at the individual in the context of social systems, which are often unfair and oppressive.
PST: Ok, so you’re a therapist by training, you went into quality improvement and then you became a Director in the Office of Consumer Affairs at a public psychiatric facility in DC. How did your ‘community’ focus influence your role there?
AML: I saw our mental health system as an operation of two communities: staff and individuals in care. I wanted to help these communities connect at the human level to create a better workplace and therapeutic environment. This was difficult because our system likes to reinforce the separation between ‘us’ and ‘them’, staff and patients. I have a background in performing arts and wondered whether there was a performance technique that could help bring the two communities together. At the time I was studying psychodrama, and was also a member of a theatre group called Synergy in Action. They use a technique called ‘playback theatre’ to dramatize people’s stories so as to invite dialogue and strengthen communities. It inspired me to think of ways in which performance could be used in our mental health system to connect the two communities. The CEO and Chief Clinical Officer were supportive so we organized a series of events that brought artists into our work.
PST: Ok, so you were experimenting with performance-based interventions to connect staff and patients, ultimately in the hope of improving outcomes. How did that look, what was the technique that you used?
AML: I used different approaches: I brought in a theatre group to teach playwriting to patients so that they could write, produce, and direct their own plays; I organized improv games between staff and clients; and I brought in a storyteller group to work with staff and patients to share stories. The underlying theme across these activities was using performance to allow both staff and patients to share stories and relate to each other.
PST: And how did that go down in the health system? What was the reaction of the staff and patients?
AML: They began to see each other beyond the role of ‘patient’ and ‘staff’. For example, during one of the storytelling workshop I remember a patient sharing how he had decided to serve in the military, and right after that story a staff member shared how his experience of joining the military had been very similar, and then shared how he hadn’t expected for a patient to have an experience similar to his.
PST: Fascinating. So in parallel to this, you founded your consultancy, Promethean Community. What made you want to take the technique from the health system into the wider community?
AML: Because communities are disconnected and disconnection is a silent killer. Feeling isolated impacts both our mental and physical health. We are social beings. Our sense of who we are doesn’t just reside in our minds. Who we think we are and how we feel about ourselves is deeply woven into our interpersonal relationships. When people create an experience together, such as through performance, they create a symbolic pause in life that can enable them to explore assumptions of who they are. The performance brings imagination into everyday scenarios that help people perceive situations in new ways. This process, which is essentially about sharing the complexity of who we are in a safe environment, helps build trust between people, which is key for communication and collaboration – and ultimately connection.
PST: So give me an example of where you’ve used this performance-based technique, in a community, and to what end?
AML: We worked with a non-profit and the Stoddert-terrace community in Washington, DC, to help them explore and challenge stigma and mental illness. In the workshop, we asked the participants – community residents, advocates, and mental health professionals – to create and rehearse a scene of a fictional character that encountered a negative situation. They then performed the scene, and we told the audience that they would see this scene again, but this time they would get a chance to try to change the scene, and if they didn’t, nothing would change. They had the opportunity to change the world on the safety of the stage. And they did! Participants stepped up, stopped the scene, and wrestled with the scenarios, and in the process practiced interventions and gained better understanding of mental illness. The stage created a common ground for community residents and healthcare providers to jointly explore and take action to address stigma in mental illness.
The community residents were so enthusiastic with the workshop and the approach that they began to use role-playing techniques in other neighbourhood association meetings. They also asked me to design another workshop, this time around the stigma that citizens face when coming home after incarceration.
The storyboards of both workshops are online and the experience made me think how this approach could scale to other communities.
PST: Scale how?
AML: I realized that the approach could potentially work anywhere by making use of the thousands of artists around the world living in the very communities we want to influence, communities in pain and conflict, unable to talk to each other. So I asked myself how might we help local artists catalyze connection in their communities? That’s why I devised HEAL – Health Equity Arts-based Labs. We work with local artists and facilitators instead of outside consultants. It helps create a platform in the community that can help them continue to engage in difficult conversations about how to co-exists and grow together.
PST: I like the idea of working with local people rather than bringing in outside consultants. But how do you know this approach leads to sustainable change?
AML: I don’t, yet. For the time being I just know that we need to reach out to these communities in new ways. Our approach actually blends methodologies that have had success in their own right, such as social labs, open space technology, human-centred design, Theory U, participatory action research, and arts-based facilitation. All of these methodologies favour non-linear explorations that are more aligned with the complex nature of human dynamics and communities. At the moment, however, most of our approaches to evaluation are linear so part of the challenge is to devise new forms of evaluation.
PST: So you’re using performing arts to surface stories within communities that help to build trust, which has the potential to create the conditions for them to self-organize, innovate and address the health challenges they face.
AML: Yes!
PST: And you’re doing so by working with local talent to create a sustainable, local platform for change that has the potential to scale.
AML: Exactly.
PST: Fascinating stuff. Wait, why the name ‘Promethean Community’?
AML: In Greek mythology, Prometheus was a titan who deeply cared for humans. After Zeus, who ruled on Mount Olympus, took away fire away from humans, it was Prometheus who stole it back to give it back to humanity. We believe many disconnected communities have lost their fire; they’ve had it stolen from them by political ideologies or conflict. We want communities to steal back their fire from these circumstances so they can create new ways of living and being collectively.
PST: We’re never far away from a Greek myth, are we? So what’s next for you?
AML: We are currently organizing two pilot projects: HEAL-Panama City and HEAL-DC, as in Washington DC. Both aim to brainstorm, build and test innovative, locally relevant, low cost, arts based interventions that will improve the health of the local community. HEAL-Panama City is organising around teen pregnancy and HEAL-DC will likely focus on access to health care or infant mortality – the local stakeholders are still deciding the focus of this one. I’m also presenting our approach at two conferences: the College of Behavioral Health Leadership’s summit and Unite for Sight’s Global Health Innovation Conference at Yale University.
PST: Well good luck with the projects, let us know how you get on, and especially let us know how you decide to evaluate your work.
AML: Will do, and thanks.
What struck me most about speaking with Andres is his desire to explore, to discover new approaches, and his clear belief that the solution to individual’s health comes from solutions at the community level.
I have no doubt that culture is a target for intervention. Whether ‘performance-based interventions’, even if delivered through local artists, is part of the solution only time will tell but I see more validity in his work than I do in public health departments believing – seemingly unshakably – that if we just print more patient information leaflets or have more adverts on buses everything will be ok. It won’t. So it’s lucky for us that people like Andres are venturing into the unknown.
