Trust the process: Community health psychology after Occupy

Community mobilisation for health: The standard model

For community health psychology, the primary answer to the question of ‘what is to be done?’ is ‘community mobilisation’. The term has acquired a variety of meanings, usefully conceptualised by Obregon and Waisbord (2010) as a contrast between ‘activist’ versus ‘pragmatist’ versions. With activist roots in Paulo Freire’s critical pedagogy, for some, community mobilisation refers to a process through which a disadvantaged community forges a common, actionable understanding of the social sources of their problems, makes plans, expresses demands and achieves positive social change (Campbell and Cornish, 2010). For others, particularly community health professionals, with a growing appreciation that health interventions cannot succeed without local community ‘buy-in’, the ‘pragmatist’ version of community mobilisation refers to any health intervention which stimulates and capitalises on the contributions of grassroots community members to endorse, support, deliver or manage a health-enhancing intervention. Community mobilisation, in the ‘pragmatist’ conception, is valued to the extent that it helps achieve measurable health gains. Indeed, from being a somewhat fringe movement challenging the status quo in the latter part of the 20th century, ‘community mobilisation’ has become mainstreamed in a wide variety of health fields in the early 21st century, incorporated as a key component of public health interventions in maternal and child health (Rath et al., 2010; Schiffman et al., 2010), polio eradication (Obregon and Waisbord, 2010), tuberculosis (TB) treatment (Kamineni et al., 2011), youth violence (Watson-Thompson et al., 2008), chronic diseases (O’Connor Duffany et al., 2011), mental health (McCabe and Davis, 2012), and HIV/AIDS (Schwartländer et al., 2011).

We suggest that both the ‘activist’ and ‘pragmatist’ versions of community mobilisation, in fact, are animated by modernist understandings of social change. By ‘modernist’ here, we refer particularly to a linear view of progress towards a predefined goal (see also Nic Giolla Easpaig et al., 2014). This modernism can be seen in each of the key terms of ‘community’, ‘health’ and ‘mobilisation’, where community is seen as a bounded group unified by a common set of concerns, where health is a goal for the individual to strive for and where communities need to be ‘mobilised’ into action, to achieve such goals. The presence of modernism seems obvious in the ‘pragmatist’ model which is a model of rational planning, in which community mobilisation figures as an efficient means of achieving a policy-defined goal (e.g. distribution of condoms, adherence to TB medicine or immunisation). But it can also be seen in the more emancipatory Freirean model, in which marginalised communities are described as moving from a state of false consciousness, to a state of critical consciousness in which they accurately identify the sources of their oppression, and forge plans and demands to progress towards their objectives (Freire, 1970, 2005). Both models can be seen to follow a linear logic, establishing a set of goals, objectives, indicators of success, and a clearly defined and hierarchical division of labour, with leaders on the top and front line workers at the bottom.

Empirically, linear models of community interventions have become less plausible, with a body of literature highlighting that processes of community change are messier and less predictable than policy and intervention manuals presume (Cornish and Ghosh, 2007; Estacio, 2012; Nolas, 2014; Speer and Christens, 2012). David Mosse (2005), in an ethnography of the intersection of British aid policy and local practice in India, shows us how the implementation of policy is far from linear, with non-governmental organisation (NGO) workers creatively doing their best to sustain contradictory policy-relevant versions and locally relevant versions of their practice, doing something quite different to taking an idea and implementing it in practice. Caoimhe Nic a Bhaird (2013), in a study of a participatory intervention promoting women’s and children’s health in a Kolkata slum, describes unintended and undesired consequences of the women’s mobilisation, including violent attacks on men and subsequent vicious retaliation. She argues that the more participatory a project, the more unpredictable it becomes, and calls for renewed flexibility and trust in local expertise, among those who fund and manage projects. Thus, there are both theoretical and empirical reasons to question a community health psychology practice that is driven by predetermined goals and instrumental action in support of defined outcomes.

Community mobilisation for health: The ‘process’ model

There is of course an alternative tradition within community health psychology, which values process as much as outcome. Although we have suggested that Freire’s work has been interpreted in a linear, programmatic way, his Pedagogy of the Oppressed (1970) is a manifesto for a process, in which he elaborates a dialogical model of ‘problem-posing education’. He draws extensively on the theologian Martin Büber to elaborate this dialogical model, which is defined as much by its ethical process, as by its educational and liberatory outcomes. Many would argue that the dual commitment to ethical processes as well as healthy outcomes is a particular characteristic of community psychology (Kagan et al., 2011; Nelson and Prilleltensky, 2005). In explaining what community psychology is, textbook authors emphasise the value-laden nature of knowledge and practice and list key community psychology values (e.g. health, self-determination and respect for diversity – Nelson and Prilleltensky, 2005; social justice, stewardship and community – Kagan et al., 2011). Stating these values is intended to establish just and respectful processes at the heart of community psychology. Nelson and Prilleltensky (2005) argue that there is a balance to be struck in the relative focus on processes and outcomes. We suggest that the mainstreaming of community mobilisation may have overly shifted that balance in favour of outcomes, hence our argument for reinvigorating community health psychology’s interest in process. More specifically, we suggest that one of the crucial tasks for community health psychology is to create appropriate processes in which people can decide on their desired outcomes.

Roberto Unger (2007), a pragmatist political philosopher, argues that the current task of intellectuals should not be to set a direction for society, but to create a way of organising ourselves that allows for perpetual collective invention, transformation and liberation. Tracing the recent dissolution of faith (within philosophy and common sense) in grand narratives and promises of utopia, Unger argues that a timely response is not to strive to identify the right goals, but to strive to create processes which enable people to creatively invent their own futures. We seek to contribute to this endeavour, taking the Occupy movement as a ‘pre-figurative action’, that is, an example, in the present, of a kind of organising that ‘prefigures’ the kind of societal future we are interested in (Kagan et al., 2011; Springer et al., 2012; Wright, 2010). If hierarchical social relations are a core source of ill-health and health inequalities, then exploring the Occupy movement’s efforts to instantiate anti-hierarchical social relations is an important endeavour.

Occupy

During 2011, 3 years into a global financial crisis producing levels of unemployment unseen for generations, and revelations of corruption and regulatory failure at the highest level of global financial institutions, a wave of protests and demands for alternatives erupted around the world, many under the label of ‘Occupy’ (Balardini, 2012). On 15 October 2011 – inspired by the Occupy Wall Street movement which had begun a month earlier, itself informed by the Indignados who had occupied Madrid’s Sol Square on 15 May – ‘Occupy’ became a global phenomenon, with thousands of people gathering in hundreds of cities around the world and creating physical ‘occupations’. In London, thousands gathered at St Paul’s Cathedral, initially with the aim of occupying the London Stock Exchange in Paternoster Square, but as dusk fell and access to the London Stock Exchange was blocked by police, 250 tents were erected on the pavement in front of St Paul’s. Over the next 4 months, until their eviction, the ‘occupiers’ established a community, with a kitchen, a library, a programme of seminars, lavatories, a security team, a press team and, perhaps most importantly, a process for organising this community through consensus-based decision-making in general assemblies.

The authors of this article have engaged with Occupy in a variety of roles. Between us, for example, we have been actively engaged in general assemblies and working groups at the London Occupy camp, organised a university seminar about the movement and engaged in participant observation and reflection about the movement as part of a university course of study. From a relatively disinterested position, we became increasingly interested. We recognise the dawning sense of possibility and opening of horizons described by others who encounter Occupy, which David Graeber (2013: 5) describes as a ‘transformative outbreak of imagination’. In particular, we were struck by the inclusive atmosphere and methods of direct democracy and were persuaded that there was much to be learnt from Occupy’s anti-hierarchical organising. We contend that the movement achieves much that community health psychology values, but in ways that challenge current approaches.

First, the movement, without specific leaders or central organisation, emerged spontaneously in 1500 cities worldwide within months (Van Gelder, 2011). Huge numbers of people self-mobilised, refuting the claim that a spirit of voluntarism is lost (e.g. Putnam, 2000). We should be interested not only in something that mobilises such passions but also in the spontaneity of the mobilisation.

Second, Occupy’s analysis of global problems was a successful intervention into societal debates, engaging the attention of news writers and politicians. It inspired the political involvement of health-care professionals (Keys, 2012; Payne, 2012) and educationalists (Manokha and Chalabi, 2012) and was supported by a majority of the US population (Gitlin, 2012; Van Gelder, 2011). It is thus an example of a grassroots movement getting their issues on the agenda attention of the powerful, a key step for community mobilisation’s impact in the world (Campbell et al., 2012).

Third, the movement not only offered a critique of the global political–economic system, it also instantiated an evolving alternative: a means of doing participatory politics through consensus-based decision-making in ‘general assemblies’. The key principle of the general assemblies is that everyone who feels they have something relevant to say about a proposal should have their perspective carefully considered (Graeber, 2013). If community health psychology is concerned about a more equitable distribution of decision-making power in human communities, Occupy offers an important case for further study.

Fourth and finally, later reinventions of Occupy, after the encampments had come to an end, have shown the creative potential and social value of such communities. When Hurricane Sandy hit New York in October 2012, almost a year after the eviction of the encampment at Zuccotti Park, the networks and skills of Occupy Wall Street were mobilised into an effective relief effort, named ‘Occupy Sandy’. Occupy Sandy volunteers distributed food and blankets, repaired communications networks and restored properties – and were widely recognised as doing so more effectively and swiftly than the official relief effort. This emergent effort affirms the creative and generative value of community networks.

Notwithstanding their successes, during late 2011 in the USA and early 2012 in London, as the occupiers were evicted by police, and the physical, personal and social demands of occupation took their toll, the movement’s momentum dissipated, and their public visibility and impact declined. Coordinating a diverse group of people through consensus decision-making was not easy and met with numerous frustrations and conflicts. Some have argued that the movement became too embroiled in managing internal concerns and disputes, to the neglect of engaging external audiences with actionable demands (Gessen, 2011).

Our treatment of the Occupy movement in this article, as we hope is clear by now, is not a comprehensive empirical or historical assessment of the movement and its various achievements and disappointments (for this, see, for example, Gitlin, 2012). Our aim is to envisage possibilities for community health psychology, aided by the concrete experience of the Occupy movement. We ask the reader to suspend judgement, for the moment, on whether Occupy was successful or unsuccessful, desirable or undesirable, to allow for a (playful) engagement with the ideas.

The following three sections take the concepts of Community, Health and Mobilisation, in turn, unpacking in more detail how each can be rethought through a focus on process, and with Occupy as a concrete example.

Community – ‘We are the 99%’

Traditionally, community health psychology views communities as groups defined by their commonalities, which may become mobilised for collective action. We shall problematise both parts of this conceptualisation of communities and collective action. Communities are typically defined by what they share, be it place, interest or identity (Mayo, 2000), in short, by being members of a common category. This traditional understanding of community has proven problematic. ‘Members’ of these predefined ‘communities’ might not identify with them, and communities are increasingly diverse, joining individuals from different places in local or global networks. Furthermore, communities tend to be dynamic: people move in and out of them as a result of changing locations, interests and identities (Howarth et al., in press). The relation of the community to collective action can also be problematised. Typically, mobilising a community is seen as a first step, to be followed by collective action, but Occupy challenges this approach.

The Occupy ‘community’ has been characterised by diversity. Occupiers were not bounded by place: occupations took place in cities all around the globe, and people flocked to the encampments from various locations. Nor did they subscribe to a shared interest. Occupy London’s initial 10-point manifesto included concerns about economic reform; defence of health, welfare, education and employment sectors; climate change; and ‘to stop wars and arms dealing’, generally aiming to achieve ‘a global system that is democratic, just and sustainable’ (Occupy London International Statement, 2011). Claiming to represent ‘the 99%’ suggested plurality and inclusivity of identities. People from a range of (not mutually exclusive) social roles took part, including students, travellers, homeless people, activists, health and social service professionals, parents, artists, educationalists and others. Respecting diversity was an explicit principle (Laibman, 2012). As well as coming from diverse backgrounds, people participated in the Occupy community in diverse ways, some taking active roles in ‘working groups’, some taking part in strategic discussions, some focusing on practical matters of managing their physical spaces, some simply showing their support by their occasional presence. So, the meanings and identities associated with Occupy were diverse, and evolved continually through discussion and practice. Rather than common identities holding the occupiers together, we suggest that it was participation in a shared project that forged community.

In contrast to understandings of collective action as emerging from existing communities, in the case of Occupy, the ‘community’ instigated change, before it even really was a community. The premise for coming together was a protest, which included a great variety of causes and critiques. The physical encampment provided an occasion for the expression of these diverse critiques. But it was not simply an unintegrated gathering of discordant voices. The occupiers had to organise their living spaces, to create a programme of education and action, and to discuss world events. The encampment was clearly ordered. Tents were erected in neat lines, meals were organised, work rotas established, outreach and educational activities took place, a communications team managed social media use and general assemblies were timetabled and well attended. Through organising the encampment and their collective activities, the occupiers constituted community. What they shared was an understanding of and commitment to a process – consensus-based decision-making in general assemblies. Although the ‘community’ was diverse rather than homogenous, these diverse individuals needed to engage with each other in order to organise. With the break-up of the camps, the momentum of the movement flagged. Graeber (2013) argues that the movement needs a physical space to meet, so that people know where to go to get involved. Perhaps a physical space – or a practical need, like Hurricane Sandy – provide the needed occasion for practical collective action. Having a project to work upon, and a process for doing so, from this perspective, is a foundation for the emergence of community.

Health – ‘caring is everyone’s business’

The issue of health has not featured as the main concern of Occupy, in the way that, for instance, inclusion, decision-making or critiques of global financial systems have been central concerns. From a broader perspective, however, each of these concerns has implications for health. Moreover, the animating concern of Occupy was to move towards a society enabling human well-being. A banner on the ‘information tent’ at the St. Paul’s encampment declared ‘caring is everyone’s business’. In this section, we shall suggest that Occupy and related contemporary movements offer critical reflections on the nature of ‘health’ as the goal of community health psychology, first, by suggesting a conceptualisation of ‘health as participation’, and second, by offering an example of how health can become a goal of broader social movements.

How to define and thus pursue ‘health’ has been a topic of critical discussion in community health psychology, particularly through a critique of the dominance of a biomedical understanding of health as a physical state of a body free from illness (Marks et al., 2005). Community health psychologists have often drawn on the World Health Organization (WHO) (1948) definition of health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. This definition is attractive because it de-medicalises ‘health’, bringing in mental and social well-being and emphasising positive well-being, not simply the absence of disease. Health and well-being, then, are often the ‘good’ that community health psychology seeks to bring about. However, the meaning of ‘well-being’ is not self-evident, and emphasis on ‘completeness’ may be unrealistic or even stigmatising for those whose health is not ‘good’ or ‘complete’.

Might Occupy offer a lens for conceptualising the ‘good’ or the ‘healthy’? As we have elaborated, in describing Occupy as an exploration of a just process rather than outcome, for Occupy, the ‘good’, is a process in which people can participate to shape their collective futures. In this light, a state of ‘health’ is one which allows a person to participate – rather than describing a particular bodily outcome to be achieved or which one might fail to achieve. A state of ‘health as participation’ includes not only bodily capacities but also wider social capacities such as capacities for communication, inclusion in social networks, availability of transport, decision-making structures that allow for participation and so on. Rather than focusing on the physical status of the body, the concern is with ‘what a body can do’ (Fox, 2011: 361). Thinking about health as participation brings us closer to professional norms in the areas of disability and rehabilitation, where, in the case of chronic conditions, aspiring for a state of ‘complete’ health, ‘free’ from illness is inappropriate. The Society for Research in Rehabilitation (2012) defines its goal, namely rehabilitation, as aiming ‘to enable people to maximise participation in meaningful social lives’. In other words, participation is the ‘good’, with health, or rehabilitation, serving to maximise that good. This perspective on health is not new, but it is an understanding of health as enabling a process and, as such, a key facet of our understanding of a process-focused community health psychology.

The second point about the goal of health concerns the relation of mobilisation around health issues to mobilisation about social issues more generally. It has been an ongoing tension for participatory health promotion that local communities may not prioritise health issues in the way that public health authorities do (Gillespie et al., 2014). Should community health psychology focus on supporting mobilisations that are specifically targeted at health issues, rather than mobilisation in general? There are some examples to suggest that social networks, skills and organisational practices from mobilisation around one political or social cause can certainly evolve to address another.

Chile’s contemporary students’ movement provides an example. Starting as the ‘Penguin Revolution’ in 2006 (Chovanec and Benitez, 2009), the movement was composed mainly of high school students protesting against the neoliberalisation of education and unequal educational opportunities, gradually building public support and peaking in 2011 with massive protests across the country (Guzman-Concha, 2012). While the movement kept a focus on its main objective of a free public education system, it gradually embraced a range of social causes including indigenous people’s rights and environmental concerns, providing a space for collective debate of interrelated issues. Currently, this space is increasingly being occupied by health concerns, particularly claims that the public health system has collapsed and completely fails patients. The main milestone of this ‘emergent group’ (Callon and Rabeharisoa, 2008) was the ‘Marcha de los Enfermos’ or ‘Sick people’s parade’. In this instance, the ‘spaces’ of contestation created by the students’ movement provided infrastructure, skills, practices and languages of mobilisation and protest that enabled a health-specific mobilisation to emerge. This example supports a position of ‘trusting the process’ of mobilisation to produce capacities for health mobilisation and to address health issues when they become priorities.

Mobilisation – ‘this is not a protest, this is a process’

Weber (1978) argued that, in modernity, human action increasingly moves towards a single type: instrumental or purposive action, that is, the strategic focus on effective means to reaching goals, without ethical considerations. In an instrumental mode of working, the selection of means to achieving ends is a matter of choosing the most effective and efficient, and the goals have pre-eminence over the process. Habermas (1989) describes the growth of an administrative, instrumental rationality as the ‘colonisation of the life-world’ by the ‘system’: activities traditionally governed by face-to-face moral interaction become governed by the faceless logic of the administrative ‘system’. We have suggested this may be happening for ‘community mobilisation’ in the health field, in which communities are ‘mobilised’ to achieve externally defined health goals. Occupy, like previous social movements, represents a critique of the ‘system’, critiquing both its outcomes for society and the dominance of an administrative rationality. Mobilisation, following Occupy, then, should be theorised and evaluated as a process, rather than being treated mainly as an effective means of achieving a particular goal.

As we have documented, attention to the process of mobilisation was a central feature of the Occupy movement. If a global financial system characterised by hierarchy, competition and self-interest was the target of their critique, Occupy’s processes provided a counter-example of a mode of self-governing characterised by horizontal and inclusive decision-making. The movement’s primary commitments were to a just and inclusive process. The tented community had to establish the means of living together as a collective, and chose the means of general assemblies using consensus decision-making. In general assemblies, there are no leaders, only facilitators of discussion, and all present have equal opportunity to suggest, contribute to, critique or, indeed, block a decision. The commitment to the process was also visible in the permanent openness to strangers (e.g. academic visitors and homeless people) to take part in the activities and to assume a role within the collective. As stated by Maeckelbergh (2012) for the case of the Spanish encampments, It was widely believed that if the types of people that can be involved is restricted, or if the types of ideas that can be expressed are limited, due to an overemphasis on a singularity of purpose, then the political space closes off to all those who have conflicting beliefs or identities. (p. 225, authors’ emphasis)

Diversity undeniably brought tension and conflict, for instance, between homeless and non-homeless participants for whom the occupation had differing significance. General assemblies were not always able to mediate between diverse positions, sometimes ending with agreement being ‘blocked’ by small numbers of members, leading to experiences of frustration and disenchantment (Gessen, 2011). These issues led to difficult debates about the principle of maximal inclusion, and whether it was, in fact, workable. While the process was not perfected (if there is such a thing as a perfect process), the collective expertise in horizontal ways of making decisions advanced significantly over the course of the occupations and offers much to be learnt (Graeber, 2013).

Through these various means, a community became organised, but not through centralised control. The goals, rules, tasks, timeframes, decisions and the whole organisation of Occupy grew out of concrete shared practices, without the need for a predetermined set of rules issued and controlled by a central administration, or enforced through a clear manifesto or charismatic leader. From the perspective of an administrative rationality, it would be unreasonable to expect that out of such ‘chaos’, a purposive structure could emerge. Yet a clear organisation did emerge. A banner at the Finsbury Park encampment in London proclaimed ‘This is not a protest, this is a process’. The point is important, but perhaps too humble. As a form of pre-figurative politics (Kagan et al., 2011), instantiating a counter-example that problematises the exclusionary practices and instrumental rationality of global capitalist politics is itself a profound protest.