The challenges of responding to the needs of the people who use our services can sometimes seem overwhelming in the voluntary sector. How does one respond to need and suffering, professionally and personally? What can one do to lend support without taking away agency?
If this is difficult, then what of the challenges around changing society to reduce the likelihood of injustice happening in the first place? Many of us contemplate these twin challenges in our work lives. If not always at the forefront of our awareness, they inform the background to how we make decisions and the ways we choose to act.
I have been thinking about change for a long time. Before coming to Tower Hamlets I worked for the voluntary organisation In Control, that led the social movement that developed and introduced Personal Budgets. Next I worked for a pressure group that sought to reconfigure inter-agency working around disadvantaged estates in parallel to supporting the empowerment of a leading cohort of residents.
Alongside my career journey I have been on a therapeutic journey that crudely has involved me claiming more of my personal power. Recently this has led to me training as a psychotherapist, specialising in Gestalt, a modality that places emphasis on a more human (less top down) relationship between therapist and client than traditional approaches.
Within Gestalt there is a small but marvellous nugget of theory developed by Arnold Beisser called the Paradoxical Theory of Change. This shines a light on an intuited sense that we can’t change people (or ourselves) by wanting them to be different. Personal change happens by becoming more aware of who we already are, by investing more in our current positions.
It is a constant lesson to me as a trainee therapist to embody what this means fully – to understand that I don’t need to try to change people, and I cannot change people. I can only ‘sit with’, accept, and support a client to become more aware of who they are already… And bingo! As if by magic, change happens.
I am a bought in believer to the Paradoxical Theory as applied to work with individuals, but what of its application to systems – for example the relationship between state institutions and civil society.
Here my instincts are initially more cautious. Chiefly because I don’t trust bureaucratic organisations to act for the good, especially where this means they must relinquish power. I believe that large organisations if left to themselves don’t change – they have an inbuilt tendency to preserve themselves at all costs. And this is why it is incredibly unusual to witness state run agencies taking steps to change themselves, or transfer resources and responsibilities at scale into the hands of citizens and communities.
The 2010 Marmott report on Health Inequalities recognised that health agencies account for only 30% of overall health improvement. This means that 70% of what is needed to improve people’s health and wellbeing cannot be delivered by health agencies.
The Marmott report is often read, therefore, as saying that other agencies – housing, employment, the police – are needed to deliver health improvement because the pressing needs that people experience are not primarily health related. This is true in so far as it goes, but there is something larger in play.
It is not a big a jump to appreciate that the 30% figure speaks to the same insight as is contained in the Paradoxical Theory, i.e. you can’t create change in a top-down way, it has to come from people’s own agency. My belief is that communities, if given the right support, possess the inherent capacity to self-organise so as to create good health.
But an additional insight – from complexity theory – is needed to understand how community health and wellbeing are created. Old fashioned population health strategies cannot work, because the approach to change is one of seeking to manage a problem (like obesity) in a top-down and linear way. Health and wellbeing are built on networks and relationships from family to the wider community, to professionals. Linear approaches to change do not allow the ‘whole system’ to reconfigure in a way such that unhealthy, dependency-creating relationships are deconstructed and new health-creating connections and relationships can form.
If you’ve ever watched starlings swarm on a late summer’s afternoon you’ll have experienced the science of complex, adaptive systems. Almost miraculously the starlings know how to regulate the distance between them, so they never collide. To the observer this organic movement looks like a slinky spring, harmoniously narrowing and bulging back and forth.
When working to change health systems our role as professionals and change agents is to create the enabling conditions that better support communities’ own capacity to self-regulate. For those of us in the voluntary sector this does not mean standing back and doing nothing. Because our state bureaucracies have an inherent resistance to change, we need to keep campaigning for, and demonstrating different ways of creating bottom up change.
But no amount of voluntary sector activity by itself will create the significant shifts that are needed to realise better health. Public agencies need to be prepared to let go of power and trust in people’s own capacity to know, and to contribute to, the solutions needed.