Promoting health or curing illness: A Child and Youth Care approach to mental health

Russel Milner

Abstract: In human services, the term “mental health” has come to imply a particular perspective on professional practice. This article describes the efforts of one community group to redefine mental health as a state of “connectedness” and examines the implications for service delivery. It is suggested that this perspective reflects what many consider to be the essence of Child and Youth Care: relationships.

As a profession, Child and Youth Care has always been more concerned with the unique experiences of each “client” than with the “systems” in which problems are identified and services delivered. Working alongside other professionals in social agencies, schools, correctional facilities, clinics, and hospitals, many Child and Youth Care workers find themselves surrounded by beliefs and practices that don’t seem to fit with their own orientation and training. Given the time-tested traditions of other professions, it is understandable that the newcomers are reluctant to challenge the status quo and settle for an uneasy accommodation within the scheme of things. Services that operate under the “mental health” banner are often considered to be the most resistant to outside influence.

While the term “mental health” has traditionally been used to describe programs based within the medical branches of service delivery, it has also become a generic term that defines a particular orientation towards the identification of problems and solutions. This focus becomes apparent whenever we talk about symptoms, syndromes, trauma, or injury, and whenever we think about our work in terms of remediation, treatment, or even healing. Such terms imply a particular relationship in which one person is afflicted and the other sets out to cure the affliction. While such relationships may serve to articulate the professional role, they do not promote the interpersonal qualities that lie at the heart of Child and Youth Care.

This article describes the efforts of one community group to redefine what is meant by the term “mental health” and suggests ways in which professional services might work towards enhancing the well-being of individuals and communities. This work was recently rejected by another professional publication on the grounds that it represents an idiosyncratic perspective that does not reflect current thinking in the field. While this might be so, the perspective offered here is certainly compatible with what many of us have come to consider to be the essence of Child and Youth Care.

TAKING ANOTHER LOOK

With its slogan “Health is Connection,” the Cowichan Valley Branch of the Canadian Mental Health Association has taken a bold and irreversible step towards redefining the field of “mental health” from its very core, through its underlying principles and parameters to its general prescriptions and methodologies. In what might seem like a simple shift in focus from the treatment of illness and dysfunction to the promotion of health and well-being, the traditional mythology that classifies, pathologizes, and medicalizes human minds and emotions is actually cast aside and replaced by a renewed curiosity about the breadth, depth, and diversity of the human subjective experience, the untapped potential of personal resources, and the formidable tenacity of the human spirit.

Clearly, this position cannot be conveniently accommodated within the popular continuum that places “treatment” at one end and “prevention” or “promotion” at the other. Our concern is not with a mental health subculture, populated by patients afflicted with diseases and disabilities being treated by experts peddling cures and symptomatic remedies, but with the broader realm in which the innate potential of all people to fully explore and experience their own lives is developed and supported. Our interest is not in the strategic eradication of poverty, unemployment, inadequate housing, and other factors commonly assumed to be the external “determinants” of health, but in why and how we create such conditions in the first place. In this sense, health is not about perpetual happiness, contentment, the absence of fear, or even the absence of disease; it is an unqualified embracing of life for its own sake, along with a recognition that we all participate in the process. And life is not about adherence to some conjured-up definition of normality or compliance with some arbitrary ideal; it is the experience and expression of what it means to be fully alive “whether we happen to be sitting in a wheel chair, shuffling through a psychiatric ward, or lying on our death bed, and whether we are in ecstasy or despair.

In all of this, we have come to question the usefulness of the term “mental health” to define any discreet area of interest. We recognize that emotions lie within the body, thoughts pass through the brain, the Self encompasses the totality of experience, and the Spirit defies containment. Since all are essentially inseparable, we consider the traditional distinction between physical and mental health to be absurd and the current emphasis upon biological determinism to be distorted and hazardous to our well-being. On the other hand, by placing us back at the centre of our own lives, we once again raise those tricky philosophical, ontological, and spiritual questions that have been conveniently avoided in the old medical-scientific world view. Fortunately, the more recent models of science seem less resistant to the freedom of human creativity and the expression of the human will.

So we are left wondering what to call the arena of our curiosity and what steps we might take in our exploration. But whatever new pathways are there to be explored, it is important from the outset to recognize that we are heading in a direction that will continue to challenge many assumptions that have become entrenched in our culture and many practices that remain essentially unquestioned. Our own challenge is to be well prepared for the journey, to be aware of our own resources to create change, to be confident in our own inherent wisdom to make up our own minds, and to find the courage to keep going.

Health is Connection
The simple, yet profound, little dictum that “Health is Connection” has far-reaching implications. Essentially, it implies that optimal health exists when a person experiences Self as an integrated whole that encompasses the body, the emotions, the mind, and the spirit. Perspectives that view these as discreet realms of experience and attempt to address them independently are inherently disconnecting and, thereby, unhealthy.

But this state of health, experienced as a pervasive sense of well-being, can only occur through connection with other Selves “without you, there can be no me. To become whole, the Self needs to be experienced, expressed from the inside and recognized from the outside. Hence, the critical context, for both health and healing, is seen to be the interpersonal (Self-Other) relationship. So, whether we are talking about traditional relational networks like the family, school, workplace, hospital, and community, or what takes place between a professional helper and a client, our concern is not so much with the structure of the arrangement as with the quality of relationships that exist between and among them. “Self-less” relationships that turn people into objects for the purposes of classification and treatment are inherently disconnecting and, thereby, unhealthy.

To take this one step further, human relationships do not take place in a vacuum; they occur within the context of the physical world. But this is not simply an external reality that serves to meet our physical needs “we are inextricably woven into the fabric of our environment. The oceans, mountains, and creatures of this planet are as much a part of us as our homes, our friends, and our families: as they thrive, so we thrive; as they get sick, so we get sick. So, our definition of health as connection must also include our relationships with our immediate environment, with the planet and with the universe as a whole, for whether we chose to be aware of it or not, these things live within our body, mind, emotions, and spirit “and vice versa. Beliefs that would separate us from our environment and view the rest of the world as being of lesser value than ourselves are inherently disconnecting and, thereby, unhealthy.

In recent years, the term “holistic” has been used to describe the many factors that seem to contribute to our state of health. Tacked on to traditional models and methods, however, this notion struggles to build bridges between various perspectives, disciplines, and methodologies that are defined by their separateness. As we use the term here, “holistic” addresses each human life as an individuated experience within a state of pre-existing unity. Expressed another way, we are each at the centre of an experience that incorporates our Selves, our relationship to others, and our integration with all that surrounds us. And it is our awareness of, and respect for, this natural state of indivisible connectedness that gives rise to a sustained sense of personal worth and well-being that we would call “health.”

Health is Generated from the Inside Out
We begin with the assumption that it is impossible for anyone to really know and understand another person's subjective experience. To claim such insight is not only arrogant, but involves a depersonalization that is potentially damaging to the well-being of both parties. To support such a claim on the basis of some pseudo-scientific biological or psychological theory that classifies and tags people according to syndromes and symptom clusters is to transform human beings into objects. To claim that those so labeled are the victims of implicit diseases, or forces beyond their control, renders them helpless. Finally, to step into another person's life on the basis of such assumptions transforms human relations into power relations.

On the other hand, it is our position that, regardless of assumed deficit or disability, each and every person possesses the resources to promote and experience her or his sense of connectedness with Self, with others, and with the world in general. In its state of unity, the natural order is neither hostile nor damaging to human life, so however disconnected or fragmented the person appears to be, the challenge remains the same: to access the resources for connection and health that lie within. Health is not a struggle against adversity, but a life-long process of seeking and sustaining wholeness. And this can only occur to the degree that the person participates directly in that process, through Self-Other contact and by creating conditions in which connectedness can grow and flourish.

Health is Self-Direction and Self-Responsibility
All of the above implies that each and every person is inherently capable of assuming increased levels of Self-direction and Self-responsibility. We are not passive participants in lives that are biologically and environmentally determined. Once again, this represents a shift away from a focus upon disease and pathology that can only be “fixed” through external “intervention.” We are complex biological, psychological, and spiritual beings, each evolving in our own way, but at the core we are all the architects of our own lives, and whatever challenges we happen to face, the pathway to health begins and ends through our own creations. From this perspective, the process involves an understanding of our circumstances, of the options that are available and of the choices that we make. Attempts by others to take away this inherent creative potential, however well-intended, represent a direct assault upon our humanness. If we are to be “helped” along the way, it can only come from those who believe that we have such resources and who are able and willing to allow their own lives to be touched by ours from a place of respect and humility. This is not a non-caring stance that responds to human suffering with indifference or blame. On the contrary, it is a stance of dignity, compassion, and belief in the sanctity of the human spirit. By contrast, attributions of diminished responsibility based upon age, gender, race, biology, or diagnostic label are objectifications that serve to undermine personal potential for Self-direction and decrease the likelihood of interpersonal connectedness.

IMPLICATIONS FOR TRADITIONAL MENTAL HEALTH PERSPECTIVES AND PRACTICES

While our concern is less with “mental health” services and more with the promotion of health and well-being, we still need to re-examine our position in relation to the arena that has traditionally held the attention of the Canadian Mental Health Association. Clearly, the stance outlined here will not be unanimously embraced by professional mental health practitioners. Yet, despite the weight of authority that lies behind traditional models and practices, we would do well to remember that there is very little evidence to support them. In fact, the only real success story has been in physical medicine where, by viewing the human body as a complex machine operating in a potentially hostile environment, medical science can claim many accomplishments. Even here, however, it must be acknowledged that the greatest contribution to the enhancement of physical well-being has been in the area of public health “our relationships with our environment. It might also be noted that despite the massive investments currently being applied to physical health research, the “fight” against most contemporary “afflictions” is less than impressive, and the new drugs and technologies aimed at symptom control are displaying increasing numbers of disturbing side-effects. Small wonder that many medical scientists are now beginning to wonder if physical health might be related to unseen processes taking place within people and the environments they create.

But if physical medicine can still point to some impressive accomplishments, the application of this medical model to the treatment of behavioural, psychological, emotional, and spiritual discomfort has been an abysmal failure. From the early insights of Sigmund Freud through the humanistic speculations of the 1960s to the complex neuro-psychological models of today, experts have made very little headway in their attempts to understand what really makes us tick. We can hardly be surprised, therefore, to learn that attempts to apply this knowledge in the form of therapeutic techniques or “cures” have made little or no discernible impact on any form of psychological distress, from transitory depression to full-blown psychosis. And given this picture, we can hardly blame psychiatrists for abandoning their short-lived love affair with time-consuming forms of psychotherapy in favor of the more demonstrable, efficient, and financially viable methods of symptom control and management.

None of this is intended to write off mental health services, or even diminish the value of mental health professionals. What we are suggesting is a fundamental shift away from the notion of victims being treated by experts and towards a new contract that places service users at the centre of their own lives and challenges practitioners to understand and respond to each person's unique experience. We are inviting professionals to make personal contact with those who seek or require their services and to use their specialized skills and knowledge to assist in accessing and mobilizing inherent personal resources. We are challenging the professions to step down from their pedestals, to abandon their carefully protected boundaries and recognize that health is a matter that embraces the whole person in body, mind, emotions, and spirit. Above all, we are urging all who demand or make use of these services to throw away the illusion of miracle cures and quick fixes and recognize the ways in which they are active creators of their own life experience. And would we present this message to a young child with an ADHD label or an adult diagnosed with schizophrenia? You bet we would, but very thoughtfully, very sensitively, and very skillfully. That’s what being a professional is all about. So do we have a new model, a vision as to what these services should look like in their ideal form? Truthfully, we don–t, and we don’t want one. The form can only emerge through the reconnection of people, with themselves and with each other.

IMPLICATIONS FOR THE PROMOTION OF HEALTH AND WELL-BEING

While we will continue to be involved in the provision and development of remedial services in the Cowichan Valley, our primary concern is with the promotion of health and well-being of individuals within the community as a whole. In this regard, our fundamental objective is to take the pressure off our beleaguered service system by shifting the primary responsivity back to people living within our community. In this, we invoke the well-established “mental health” principle that people who experience personal control and efficacy in their own lives are more likely to achieve and sustain a sense of personal worth and well-being.

Again, we want to stress that this is not a disguised strategy to reduce the quality, quantity, or diversity of available professional services. Rather, it is our hope that professional practitioners and service providers will discover a renewed lease on life by creating new approaches in collaboration with the community as a whole. In this way, they can begin to play their part in dismantling the long standing co-dependent relationship between themselves and those who seek their services. On the other side of the coin, we anticipate that service users will become more knowledgeable, discriminating, and responsible in dealing with practitioners and the service delivery system.

From the outset, we wish to make a clear distinction between health promotion and dis-ease prevention. For us, the former refers to the identification and mobilization of resources that nurture and sustain increased levels of personal and community well-being. It is founded upon the assumption that health, in body, mind, and spirit, is a natural state that is embraced and supported by the natural order. From this perspective, human growth and development occur when the individual discovers her or his creative and expressive place within the relational world. Prevention, on the other hand, refers to the identification and eradication of elements considered to be potentially unpleasant or harmful. It tends to be founded upon the assumption that health is a state that must be wrought from potentially hostile and dangerous circumstances. From this perspective, health can be only be maintained through successfully combatting those elements capable of inflicting discomfort, distress, disability and, finally, death. So, while promotion and prevention are frequently used by health experts in the same breath, we choose to see them as very different concepts. Obviously, it would be absurd for us to suggest that there is no place on this planet for preventive action. The question at hand, is which of these two positions should take primacy in the quest for the enhancement of well-being? Until further notice, it is our intention to stick with the former.

So What Do We Do Now?
Given our idiosyncratic approach to the promotion of health and well-being, we now face the reality that there are no carefully formulated models to examine and few systematically devised strategies to replicate. This is probably a blessing, since we would be traitors to our own cause if we developed an intervention or treatment strategy to be imposed on our community. We can only begin by recognizing that the resources for any such development lie within people who currently reside within this community. By the same token, however, we are also members of the community, and if we truly believe that health is developed through connection, then we should really get ourselves out there -not to convince others that we have answers (because we don–t), but to offer simple personal connections while supporting others who wish to do the same. And, of course, it would be sheer hypocrisy if we didn’t “walk the talk” ourselves through the development of our own interpersonal relationships and our own commitment to Self-direction and Self-responsibility.

If this sounds simple or simplistic, our experience thus far suggests the opposite. It is much easier to slip into the role of expert, healer, advocate, or social activist bent on enhancing other people’s lives than to simply bring the Self forward with no other agenda than to make connection with others. On the other hand, it has been our experience that relationships based simply upon the presentation of Self and curiosity about others quickly become strangely profound. This doesn’t mean that our desires, beliefs, and abilities must be held in storage “they are part of who we are. The difference lies in the intention to allow connection to occur rather than to try to negotiate some preconceived or familiar relational arrangement. It’s not easy.

From an organizational perspective, we have managed to carve out an overall mission statement, a set of related goals, and a series of agreed-upon strategies. If this sounds like a remarkably conventional outcome to an un conventional build-up, a quick glance at our planning document will reveal one possible variation from the norm. All of the statements made refer exclusively to what we intend to do, and not what we anticipate, or even hope, that others will do in response. While we talk about creating options, providing opportunities, and encouraging connections, we know that we will never hold ourselves responsible for how others might respond. We identify ways to examine the potential resources for health within our community, but we have no illusions about ourselves being the experts or even the most knowledgeable observers. Occasionally, we use the verb “to facilitate,” but always with the understanding that the commitment and the energy will come from those who either request or choose to participate. In other words, we are prepared to act on our own behalf but refuse the temptation to invest in or assume responsibility for the actions of others. This approach to organizational planning is the only one that makes sense, given our expressed views on the subject of health and well-being.

So What Works?
Based upon the responses of others toward us, we have explored a number of ways to promote connection in our particular community. We have facilitated “story nights” where people come to simply talk or listen to each other. Sometimes particular themes have emerged and, of course, we were particularly fascinated by people who spoke of their efforts to reclaim their lives from the black hole of sickness and despair. At other times people have simply wanted to talk about their parents or bring forward their ideas on raising kids. The topics themselves are not the primary issue, however; what matters is the connection that takes place within the group.

In the same vein, we have sponsored mini-conferences on a variety of topics related to matters of health and well-being. These gatherings have brought mental health professionals together with non-professionals, and our only significant role has been to intervene whenever we sense that the interpersonal quality of the interaction has been abandoned. While we have been there to encourage and support more long-standing connections, essentially we leave that to the participants themselves.

To offer another example, we found ourselves working with a group of teenagers attempting to establish a youth centre in their town. Although they had attracted a large number of adults and potential sponsors who wanted to “help kids,” these young people were determined to maintain control of their own creation. Here, again, we experienced that hazy yet critical distinction between offering support and taking over “where the helper actually becomes invested in the helplessness of the other. It’s amazing how seductive, though well-intended, helpers can be when they believe that they have the resources to fix or improve the life of others. But this particular group of young people was not about to be seduced into helplessness, even if the pay-offs seemed immediate and substantial. With enlightened volunteer support, they continued to pursue their own interests while creating the relationships they wanted with their supporters and carving out Self-responsible connection with community groups, ranging from ourselves to the local police detachment. The problem is that if someone comes along to ask us to justify our existence, to demonstrate what we did to create a new youth centre, our answer would be unlikely to impress our sponsors. The truth is that we simply hung around a little, responded responsibly with whatever support we could offer, and generally stayed in the background. The accomplishments and “measurable outcomes” all belong to the youth themselves. We would suggest that professional practitioners might try taking the same stance in their work with their “clients” or “patients.”

A NOT-TOO-FINAL WORD

The philosophical position and pragmatic changes discussed in this article have not come easily. Our decision to move away from service delivery and into community health promotion created profound risks to our identity, our role, and our financial viability. We continue to struggle within and among ourselves to be clear about our “purpose,” and we are constantly challenged by others who believe that we have abandoned those who have always needed us the most “the service providers and the service users. We struggle to find alternative sources of funding and support for our modest operation and to resist the urging of those who are looking for nifty new solutions to problems identified as concerning “mental health.” But there really can be no turning back to what we have now rejected. Life, after all, is an ongoing experience of shifting conditions and creations “that’s what keeps us alive, healthy, and human.