Transformation over Amelioration: Introducing Structural Competency in Undergraduate Education

(The above image, drawn by my friend who prefers to stay anonymous, is a reference to the famous Don Quixote scene with windmills. This scene has always been one of my favourite moments in the history of literature. There are many ways to interpret the meaning behind windmills battle and my aim here is not to engage in literary interpretation; my aim is to give context to my blog post from a personal standpoint. We all encounter windmills and experience windmill battles in the everydayness of our life. Windmills are everywhere. They are gigantic, they all look the same, they come in groups, they blow in the same direction. Don Quixote doesn’t beat the ferocious giants in Cervantes’s novel, but that is not the point – one person can’t change the system. What I think is more important is that Don Quixote undergoes a transformative experience through reading chivalric novels which empowers him to go and fight for what he stands for. I wonder what it would look like if we were to encourage transformation and transformative learning opportunities for students in the early days of undergraduate education? If we were to create spaces in which students would feel touched and moved to action by what they co-learn at Universities? If knowledge was co-created, inspired, underpinned by creative and critical thinking, and value-laden rather then didactic, information-driven and off-you-go?

This blog is about transformation in education.

Throughout this blog post, I use the pronouns “we” and “us” a lot. By that, I am largely referring to the western society where I live. I am also writing this as an osteopath who is active on social media such as Twitter, Facebook, and Instagram, and where I am largely exposed to opinions by colleagues from both osteopathy and physiotherapy professions. I am not affiliated with any educational institution and this post is not targeted at any institution in particular. This blog is written in the spirit of reflection, observation and invitation. The “I” is deeply embedded and held accountable in “We”.)

INTRODUCTION

Is this my mother who is gripped, albeit wrongly, with guilt? Is she in this moment wondering what she did or did not do to ensure her baby, her Monte, be kept safe from the nightmare he’s been cast into? Is my mother the fallout, the collateral damage in the battle to elevate personal responsibility over everything, over all those decisions that were made about state budget priorities, about wages, about the presence of police, and even about damn grocery stores and access to quality food?

Here, in this hour and in this place, in this system of law that is supposed to be adversarial but is instead where the players all side up against her son, my mother accesses the only feeling she’d ever been allowed to access freely. Guilt. Guilt for having a baby young. Guilt for not blindly following patriarchal religious protocols. Guilt for being poor. Guilt for not keeping mental illness out of her son’s brain. Guilt that she could not stop a group of people from divorcing themselves from a useful definition of humanity. Guilt that she could not keep those moral monsters from harming her baby. I put my arms around my precious mother

The excerpt is taken from the memoir “When they call you a terrorist” by Patrisse Khan-Cullors and Asha Bandele. Written through a deeply evocative personal narrative penetrated by political analysis and lived experience of state violence, the memoir portrays the birth of the Black Lives Matter (BLM) movement. In this scene, Monte who has been incarcerated by the police and charged with terrorism, is in the court with his mother and sister. 

Before I outline the aims and hopes of this blog post, the reader is invited to take a pause and re-read the excerpt. I invite the reader to reflect on four things:

  1. What forms of social oppression is Monte’s mother living under? 

2. Remember the times when Monte’s mother visited your clinic – what was your process of self-reflection? 

3. Imagine Monte’s mother is about to enter your clinic – I invite you to reflect on the privileges and penalties you might be bringing into the social situation of that clinical encounter. Write them down. Ask yourself: what are the aspects of her experience that you do and do not share? 

4. What could you do in order to create a safe place for Monte’s mother? 

AIMS AND HOPES FOR THE BLOG

In this blog post I will propose that if educational institutions want to be dedicated to genuine anti-racial curricula, critical frameworks such as Narrative Medicine and Structural Competency need to be introduced in undergraduate education. I will use quotes from various literary resources that have bolstered and inspired me through my life in order to give weight to my arguments and to encourage reflection. I believe that nothing can transform a human’s heart as powerfully as good literature and art, if approached with genuine curiosity and critical reflection. The position from which I write is drenched in deep passion and love for these subjects. I will approach and examine the framework of Narrative Medicine and Structural Competency through the lens of racial injustice because, in the web of all our current crises, the racial injustice is the most deeply and tragically embedded one. At the end of the post, I will also introduce Narrative Humility as an epistemological stance for Structural Competency as previously argued by DasGupta (2008) and Tsavet et al. (2014). This paper was partly inspired by a recent Twitter post where a physiotherapist posed a question: “Is obesity a choice?” to which 45% answered yes. To think that obesity is a choice is to assume that we live in a world where every human being has a privilege of choice in the first place. Not only is this oblivious to the society we live in, it is rather inimical to the work that we do as healthcare providers. We need, and must do better.

WHY WE NEED CRITICAL FRAMEWORKS IN EDUCATION

The Master’s tools will never dismantle the Master’s house“, Audre Lorde, 1979

The word apocalypse comes from a Greek word apokálypsis, a derivative of the verb apokalýptein which means “to take the cover off”, “to uncover”, “to lay bare”, “to reveal’. Apocalypse is thus a state in which a veil or curtain is about to be lifted to reveal something that has been hidden and suppressed. The past eighteen months of the Covid-19 pandemic have been apocalyptic in the true meaning of the word as they have exposed much of what has been hidden for decades. Yes, I am talking about the BLM movement, George Floyd, Sabina Nessa, Sarah Everard, and multiple other health and social inequities and structures at play that the Covid-19 crisis unmasked all at once. Not to say that these tragedies have not plagued our humankind for a very long time, but the pandemic had created a distraction-less environment in which nobody had an excuse to look away! The thin curtain of privilege and oblivion was not as soundproof as once thought.

As a response to the Covid-19 apocalypse, many schools and Universities have started talking about their dedication to anti-racist curriculum. But with many educational institutions such actions were performative and did not ignite any real transformation and change. I would like to borrow the term by Fox et al. (2009a) and call such remedial actions ameliorative practices. Ameliorative practices seek to create change within a system without critically examining and deconstructing values, assumptions and underlying power arrangements that underpin the systems and institutions (Fox et al, 2009a). Gutierrez (2020) painstakingly highlights the futility and danger of such practices: 

Consider an institution that says it’s committed to anti-racism and has added mandatory antiracism training, broadcasting that “We’re paying attention to this topic.” Yet it has no Black or Latinx senior faculty, supports no research dedicated to studying racism specifically, has poor retention rates of Black and Latinx clinicians, has a history of retaliating against employees or clinicians who speak up, and presents no plan for addressing these issues or has excluded its own members of color from participating in the planning. What does a new anti-racism curriculum do, set against the backdrop of these structurally racist practices? It directs attention away from their very examination

As an antidote to ameliorative practices, I want to propose two critical and transformative frameworks that seek not to echo populistic ideas, but to use radical critical reflection in order to examine and deconstruct our implicit biases, and the gaze through which we see the world, by approaching and moving us from within. These frameworks are Narrative Medicine and Structural Competency.

“The Master’s tools will never dismantle the Master’s house” are words uttered by a formidable poet, feminist and lesbian Audre Lorde at the feminist conference in 1979. Traditional methodologies and theories, conventional western-society formed epistemologies, and ameliorative practices at large are Master’s tools that can not and will not dismantle the Master’s house – meaning the institutional racism and other social injustice that pervade our society (Bowleg, 2021; Paton et al, 2020). I believe that we need more critical approaches to dismantle the putrid and acidic spaces in which we have seemingly become comfortable in: in education, in clinical practice, in the world. The following paragraphs will outline the two frameworks I am proposing here. 

NARRATIVE MEDICINE 

Narrative Medicine is a critical Medical Humanities that has its own body of knowledge that is infused with intersectionality, qualitative research methods, and creative and reflective practices in place. It is critical in an epistemic sense, in that it pays deep attention to the matters of power and privileges, and examines social injustices through the means of language and art. Narrative Medicine scholars use excerpts of literary fiction, art, poetry as platforms to attend to the matters of power and privilege, using that third object as a catalyst for greater collective consciousness. By paying radical attention to language, narratively competent practitioners learn how to read social structures embedded in language. Educators delivering this type of programme need to be careful when choosing the third object for close reading/looking and make sure they are being truly representative. They ought to be reflective not only of what they teach but how they teach it (Tsavet et al, 2014). As a critical Health Humanities, Narrative Medicine rests on two pedagogical pillars that exist bidirectionally: Structural Competency and Narrative Humility. In the following sections I will introduce these and use them as filters to help engage with a deeper understanding of Monte’s mother’s story.

STRUCTURAL COMPETENCY 

Structural Competency is a novel critical framework designed by Metzl and Hansen (2014) and it is best defined as the “trained ability to discern how a host of issues defined clinically as symptoms, attitudes, or diseases (e.g., depression, hypertension, obesity, smoking, medication “non-compliance,” trauma, psychosis) also represent the downstream implications of a number of upstream decisions about such matters as health care and food delivery systems, zoning laws, urban and rural infrastructures, medicalization, or even about the very definitions of illness and health”. In more simpler term, Structural Competency is about critical attention to power and privilege. When proposing treatments and management plans, understanding social and structural powers and forces at play is an essential skill of each healthcare provider. For example, before proposing exercise and fresh vegetables we may want to ask ourselves whether the person has access to such resources. Before calling people “messed up”, “difficult”, “malingerers”, “hysterical”, “obese”, and “psychosocial”, we may want to take a more critical look at the wider picture. What are the potential embedded oppressive social conditions that might be enacted by giving such advice out of context? 

In a typical Narrative Medicine workshop, students exercise and sharpen the skill of Structural Competency. If we look back at the excerpt above, we should be able to recognise that Monte’s mother lives a life at the intersections of gender, class and race oppression. These oppressions are in dialogue with each other and they all serve to delimit her sense of freedom, her dignity and her humanity, with one goal in mind: to change her mind about herself and ultimately to annihilate her life. This kind of social analysis is different to the traditional framework of Cultural Competency in that it focuses not only on the sociocultural conditions that exist outside of us, but it is inviting us to reflect on our own frames of listening and to the spaces within us. Structural competency is thus inextricably coupled with the pedagogical pillar of Narrative Humility. 

NARRATIVE HUMILITY 

Narrative Humility is a term coined by Sayantani DasGupta, one of the Narrative Medicine faculty members at Columbia University. Narrative humility “acknowledges that our patients’ stories are not objects that we can comprehend or master, but rather dynamic entities that we can approach and engage with, while simultaneously remaining open to their ambiguity and contradiction, and engaging in constant self-evaluation and self-critique about issues such as our own role in the story, our expectations of the story, our responsibilities to the story, and our identifications with the story—how the story attracts or repels us because it reminds us of any number of personal stories” (DasGupta, 2008). In other words, no matter how many times we hear the patient’s story we can and never will know it in its totality. When students of Narrative Medicine join their gazes in order to observe the third object, they become aware of the multiple perspectives they each posses, their own biases and prejudices etched into those perspectives, and the awareness that each story has an element of unfamiliarity about it. Narrative Humility inspires conversation around Emanuele Levinas’s philosophy of the Other and the notion that “the other always lies beyond the comprehension of the self”. As an epistemological stance, this type of humility demands that we, as clinicians, become aware of our own frames of listening, and asks us to examine ways in which we might be contributing to the socially unjust conditions. Within an educational setting, this type of epistemological humility is an invitation to educators to question whether they see their students as co-learners or they see themselves as didactic educators and information providers. An educator who is inviting students to be vulnerable but himself is not modelling that vulnerability is enacting oppressive structures and misusing the position of power. As with Structural Competency, Narrative Humility is about commitment to accountability. 

By attending to Monte’s mother’s story, I may start by recognising my own privilege as a white European woman who, in pursuit of her dreams in this life, not once had to think that colour of her skin may get in the way. Even the very act of pursuing dreams is a privilege I am afforded access and privileges simply by virtue of my skin colour, outlook, sexual orientation which are not deemed threatening to the society I live in. I may want to ask myself, am I a safe person for Monte’s mum? Informed by such thoughts, I may choose to be very attentive to the language I use in the consultation. I may speak less and give her space to tell her story. I may want to recognise that there are parts of her existence that I will never understand in totality but I seek to know so I can inform myself, so I do no harm in my listening to the stories I hear. 

A CALL FOR ACTION: TRANSFORMATION NOT AMELIORATION

The times we are living in demand our attention and immediate action. Simply talking and paying the lip service to the biopsychosocial model and anti-colonial curriculum is not enough. There need to be real practices in place otherwise we run the risk of doing performance business that reifies oppressive structures. I invite Universities to start changing their cleaning practices (Guerrez, 2021) and hang their laundry in the front garden. Introducing critical Health Humanities is one way to start enacting this process, and it is crucial that it is accompanied by inside-out action. 

Researchers who are in the position of power, should seek to disseminate the research that often stays covered in dust behind the walls of academia: one good example of that is the Words Matter podcast looking at Qualitative Methods and CauseHealth series. Researchers should also encourage their students to take research in matters of racism, gender and wider sociocultural aspects in order to open up spaces for further dialogue. Universities should also start hosting literary scholars, philosophers, disability activists, patient advocates. University staff needs to be comprised of black and brown people, people of wider ethnic minorities, people who live outside of sexually hetero-normative constructs of society; all the people who are regularly marginalised. If this radical practice is not in place then education faces the risk of enacting hierarchical and patriarchal practices. 

If we truly desire to see a change, we need transformation not amelioration (Fox et al, 2009a), we need knowledge not for the sake of knowledge (Collins, 2019) but knowledge that is going to transform us from deep within, bring us face to face with our own racism, homophobia and abjection; knowledge that is going to not only touch us, but move us to action. We need revolutionary and apocalyptic knowledge: a kind of knowledge that reveals.

EPILOGUE 

Some may read my commentary as a form of naiveté or wishful thinking that one can change the system by changing individual frames of mind and/or introducing ‘’some art’’ in schools. I would like to reply to those comments by echoing the words of journalist Reni Eddo-Lodge: It doesn’t matter what you do, as long as you’re doing something. I believe we each have responsibility for what is happening in the world right now. This is therefore not about naiveté and tragic optimism as much as it is about responsibility and hope and we all need hope in this life. Hope grounded in sober narrative, collective discernment and faith in better tomorrow. 

Acknowledgments: Thank you to my dear friend and colleague Robert Shaw for proof reading my blog and for supporting my desire to write about these issues.

People who inspired this blog: all my patients in Lincolnshire Community Pain Management Service, my dear colleague Laura Rathbone, and peers from the Narrative Medicine course at Columbia University.

REFERENCES:

Collins, P. H. (2019). Intersectionality as critical social theory. Duke University.

Bowleg, L. (2021) The Master’s Tools Will Never Dismantle the Master’s House: Ten Critical Lessons for Black and Other Health Equity Researchers of Color. 48(3)

DasGupta, S (2008) Narrative Humility The Lancet 371

Evans, S., Duckett P., Lawthom R., Kivell N. (2016) Positioning the Critical in Psychology Community

Fox, D., Prilleltensky, I., & Austin, S. (Eds.). (2009a). Critical psychology: An introduction. Sage

Gutierrez, K. (2020) The Performance of “Antiracism Curricula” The New England Journal of Medicine

Khan-Cullors, Patrisse, and Asha Bandele. When They Call You a Terrorist: A Black Lives Matter Memoir. New York: St. Martin’s Press, 2018.

Lorde, A. (1984b). Sister outsider: Essays and speeches. Crossing Press

Metzl, J. & Hansen, H. (2014) Structural competency: Theorizing a new medical engagement with stigma and inequality

Paton, M., Naidu T., Wyatt T.R., (2020) Dismantling the master’s house: new ways of knowing for equity and social justice in health professions education

Reni Eddo-Lodge, Why I’m No Longer Talking to White People About Race. (2017)

Tsevat R., Sinha, A., Gutierrez, K. and DasGupta, S. (2014) Bringing Home the Health Humanities: Narrative Humility, Structural Competency, and Engaged Pedagogy

Published by shapingstoriestogether

Osteopath and Narrative Medicine scholar-in-becoming

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