Keywords

1 Introduction

A culture’s distinctive values are often a product of its history. Totalitarian, democratic, individual, and communitarian values, not to mention a whole raft of religious and spiritual values, all offer cases in point. This much is familiar. Less well recognized is the extent to which a culture’s history may drive its characteristic ways of processing or working with values.

It is this processing aspect of cultural values that is illustrated in this chapter by a story from the Balkan region of Eastern Europe, the story of Dr. Petrov and his neighbor Ivailo. The Balkan history of repeated colonization has given its people a particular capacity for balancing different and at times conflicting sets of values. Balkan people survived colonization by learning to live ‘at the edge of compromise’ between their own values and the values of their colonizers.

Here, Dr. Petrov’s uniquely Balkan capacity for living at the edge of compromise allows him to balance the conflicting values involved in supporting his neighbor, Ivailo, through a difficult period.

2 Narrative: The Story of Dr Petrov and His Neighbor, Ivailo

Ivailo (not his real name) was a 48 year old Bulgarian working as a psychiatric hospital attendant (orderly) and in the evenings on a part-time basis as a taxi driver. He had suffered several clinical episodes over the past 10 years diagnosed as psychotic mania with associated history of alcohol abuse.

His mother left Bulgaria in the early 1990s and went to live in New Zealand. His father although remaining in Bulgaria had been a major source of various traumatic experiences throughout Ivailo’s life. His father was constantly abusive, with both verbal and physical aggressive behavior, and entering into frequent conflicts about property and relationships. He repeatedly threatened to disinherit Ivailo and leave him and his family practically homeless.

Ivailo lived in the same house with his father, wife and two adolescent children until July 2011 when his father died from a rapidly progressive cancer. His wife had been unsupportive throughout and now set out to antagonize Ivailo’s two sons against him. In September 2011 Ivailo stopped taking his medication and gradually returned to abusing alcohol.

A couple of months later during a brief period of sick leave he turned up at the home of a psychiatrist, Dr Petrov (again, not his real name), who was living nearby, asking for a loan. Dr Petrov was not Ivailo’s physician but recognized that his behavior was unusual: he was struck by his somewhat awkward and untidy appearance and unusual behaviour. After talking with his (Ivailo’s) wife however he came to the view that Ivailo’s presentation was understandable given his complicated family situation and low income.

He thus decided to help Ivailo with a loan while encouraging him to take care and to consult his own doctor. Ivailo came back 3 weeks later asking for a further loan but now in a more obviously disturbed state. On this occasion Dr Petrov refused the loan but again urged Ivailo as a friend to see his doctor.

Ivailo however did not seek medical help and over the following 18 months his condition deteriorated to the point that his behavior became destructive and dangerous. Following a further period of sick leave he was finally admitted as a patient to the hospital where he had previously worked as an attendant.

From this point Ivailo’s situation gradually improved. Over 3 months of in-patient treatment he restarted his medication and stopped drinking. Within a few months of discharge he was well enough to return to his job as an attendant in the same acute psychiatric ward on which he had been a patient. Ivailo’s family problems continued. But he now felt more prepared to cope with them while holding down his job.

One of the first things Ivailo did after being discharged from hospital was to return Dr Petrov’s loan.

3 What Values and Whose?

Reading this story, the reader may reasonably want more information particularly about Ivailo. Was his ‘relapse’ perhaps a pathological grief reaction to the death of his abusive Father, for example, and what were his actual symptoms? Without such information, we are left speculating about his values, about what mattered or was important to him. We are in the dark similarly about Ivailo’s wife. What values were driving her antagonism, for example? What about Ivailo’s father? Why did his mother leave so early in his life and move to the other side of the world? Then again, the institutions involved would have had their own priorities. That Ivailo was allowed to return to work in the same hospital suggests a very supportive employment policy.

As to Dr. Petrov, though, it is clear from the information provided that in deciding how to help Ivailo, he was faced with a number of conflicting values. On the one hand, there were considerations of prudence. Giving Ivailo a loan might seem (Dr Petrov’s wife thought it was) financially risky. Not only that but from a professional perspective, it might be seen as breeching professional boundaries. True, Dr. Petrov was not actually Ivailo’s doctor. But he was putting his professional reputation on the line. One of Dr. Petrov’s senior colleagues commented ‘you did something quite stupid giving him money and not helping the police to catch him’.

Dr. Petrov was well aware of these negative considerations. On the other hand, however, and on the positive side, he saw Ivailo as someone in trouble. As a neighbor, he simply wanted to help Ivailo in the difficult situation in which he knew him to be. Although not exactly friends, they had been acquaintances for many years. Dr. Petrov also knew Ivailo through his work at the hospital. In this context, he had had experience of him when well as a hard working and conscientious character.

Dr. Petrov balanced these conflicting values differently on the two occasions when Ivailo asked him for a loan. On the first occasion, he said ‘yes’ though encouraging Ivailo to seek medical help. On the second occasion, only 3 weeks later, he refused the loan. In the interim, Ivailo had not sought medical help and he was now in ‘a more obviously disturbed state’. Note therefore that the same two sets of values were in play on both occasions but balanced differently according to the particular circumstances presented.

Balancing values in this way is what is called in values-based practice dissensual decision-making. As indicated in chapter 1, ‘Surprised by Values: An Introduction to Values-Based Practice and the Use of Personal Narratives in this Book’ of this book dissensus is difficult. One of the aims of training in values-based practice is to develop the skills that support dissensual decision-making. Dr. Petrov’s instinctive use of dissensual decision-making was supported by his Balkan cultural heritage of living under colonization at the edge of compromise.

4 The Influences of Culture

Bulgaria’s history is a history of serial colonial domination running from the Ottoman period (1396–1878) through to its recent period as a satellite of the Soviet Union.

Throughout the Ottoman occupation, Bulgarians adopted many survival strategies. The indigenous Christian population for example were obliged to build their churches so that they appeared lower than Muslim mosques. The Twentieth Century saw the adoption of a number of similar compromises. Between 1934 and 1944, for example, the Saxe-Coburg-Gotha governing dynasty, backed by a number of pro German politicians, brought Bulgaria into alliance with the Axis and National-Socialist Germany. It was in response to this that King Boris III captured the idea of ‘living at the edge of compromise’: he advised his diplomats to be “always with Germany and never against Russia”. King Boris’ son, Simeon II, embodied the same ‘edge of compromise’ principle by reigning as King from 1943 to 1946 and then going on to become the Prime Minister of a republican Bulgaria from 2001 to 2005.

A further example of the Bulgarian capacity for compromise is provided by the way her period as a satellite of the Soviet Union came to an end (in 1989). The demise of the Soviet empire in most Eastern and Central communist countries was by popular uprisings of the people against the local regime. In Bulgaria, the regime was deposed from within by a party coup d’état.

5 Implications for Values-Based Practice

Balkan pluralism as evinced by Dr. Petrov in his relationship with Ivailo offers a direct response to the central challenge for implementing values-based practice noted in our introduction to values-based practice (chapter 1 and in a number of other contributions to this book, the challenge of pluralism.

Table 20.1 Some of the areas of values-based practice involved in the story of Dr. Petrov and Ivailo
Full size table

The elements of values-based practice tend to work together as a whole. The story of Dr. Petrov and Ivailo more fully explicated illustrates many aspects of values-based practice [1]. We summarize these in Table 20.1. In this commentary, however, we focus on the example it gives us of dissensual decision-making supported in particular by a key aspect of values-based communication skills, a focus on strengths as well as needs and difficulties.

5.1 Balkan Pluralism and the Default to Monism

First, then, what has this story to tell us about the challenge of pluralism? Values-based practice, we pointed out in chapter 1, is top-to-bottom—from its theoretical basis in (a particular take on) the logic of values through its reliance on process to its outputs in balanced dissensual decision-making—irreducibly pluralistic in nature. Yet, when it comes to values our default position, as we put it, drawing on the work of the moral and political philosopher Isaiah Berlin [2] is not pluralism but monism.

Good idea, then, values-based practice may be in principle but what chance it has in practice? Like so many other good ideas in principle, it looks set to fail the test of implementation. Values-based practice, it seems, has an inbuilt design flaw. Intrinsically pluralistic, it is ill-fitted to a value environment dominated by monism. We gave a number of examples in chapter 1 of Berlin’s default to monism at work, notably, in the case of mental health, with the values-based Guiding Principles supporting implementation of the UK’s Mental Health Act 2007.

But Balkan pluralism puts a very different and more optimistic slant on all this. It points to and indeed challenges an unacknowledged premise guiding Berlin’s observations and the implications we took from them for the challenges of implementing values-based practice. The unacknowledged premise is that the default to monism is inbuilt in human nature. It is as it were in our value genes. Balkan pluralism points to the possibility that the default to monism may be more ‘nurture than nature’. As indicated above, Balkan pluralism is a learned behavior, a survival strategy adopted in response to several hundred years of serial colonization.

5.2 Dr Petrov as a Values-Based Practitioner

It will be worth reflecting for a moment on how closely Dr. Petrov adopted, by nature, a values-based dissensual balance in his dealings with Ivailo. Dr. Petrov was caught between the (in this instance) conflicting demands of financial prudence and humanitarian neighborliness. Both values were in play. Both had the status of prima facie principles. They formed part of what amounted to a framework of (implicit) values shared by Dr. Petrov, his colleagues, and family and, given the happy ending of the story, Ivailo himself.

Neither value moreover, neither financial prudence nor humanitarian neighborliness, was somehow to be simply set aside. There was no general rule that placed one against the other in principle. The two values had instead to be balanced one against the other according to the particular circumstances presented by the decision in question. On the first occasion of Ivailo requesting a loan, humanitarian neighborliness won out for Dr. Petrov against financial prudence. Both values, however, consistently with values-based dissensual decision-making, remained in play. One indication of this is that others weighed them differently (Dr Petrov’s senior colleague weighed them differently). On the second occasion, the balance, for Dr. Petrov, came out the other way around, with financial prudence outweighing humanitarian neighborliness.

Also important in this story is the attention paid by Dr. Petrov not just to the needs and difficulties experienced by Ivailo but also to his strengths. You will recall from chapter 1, ‘Surprised by Values: An Introduction to Values-Based Practice and the Use of Personal Narratives in this Book’ that exploring strengths, aspirations, and resources (StAR Values) as well as needs and difficulties is a key aspect of the communication skills for values-based practice. Thus, the familiar (to many medical students, at least in the UK) acronym ICE is used in communication skills training as a reminder to explore a patient’s Ideas, Concerns, and Expectations; but this becomes in values-based practice, ICE StAR. On coming to his balanced dissensual decision, Dr. Petrov we are told knew Ivailo through his contact with him at the hospital where he was employed, to be ‘hard working and conscientious’. This information thus critically shifts our picture of Ivailo. Without it, he is a failed family man and employee on the downward slope toward destitution. With it, with the information about his strengths (his StAR Values), he is a man struggling with a devastating life situation but with the personal resources for recovery. This proved to be so in the event. He recovered and indeed immediately repaid Dr. Petrov’s loan.

5.3 Implementing Values-Based Practice

Dr. Petrov, it is worth pointing out, was not at the time of his interactions with Ivailo, consciously engaged in a dissensual balancing of values. He had indeed at this stage in his career never heard of values-based practice. This should not come as a surprise. As emphasized in chapter 1, values-based practice is all about recognizing and building on best practice. Indeed, the point of the story of Dr. Petrov and Ivailo is precisely to illustrate the natural capacity of Balkan people for value pluralism derived from their cultural history of colonization. Balkan people offer a timely exception to Berlin’s default to monism, thus highlighting and challenging Berlin’s (and our) hidden premise of values defaulting to monism.

Merely recognizing that the default to monism can be learned and, hence, unlearned, opens up new possibilities for implementation. With its origins in philosophy, it is perhaps natural that implementation strategies for values-based practice have relied perhaps over-heavily on argument. Ideas can after all change the world. As to the arguments of philosophers, Bertrand Russell, writing in the mid-twentieth century, at about the same time and with many of the same concerns as Isaiah Berlin, argued that philosophy could teach us ‘how to live without certainty, and yet without being paralysed by hesitation’ [3, p. 14]. There could be no more accurate statement of the aims of values-based practice. Yet to date, as we saw in chapter 1, the resources of analytical, ethical, legal, and professional arguments, appealing to ‘win-win’ and other supposedly motivating outcomes, have all been deployed against the default to monism to only limited effect.

Understood rather as learned behavior, however, the default to monism is opened up to that whole range of additional empirical resources represented by the sciences of change management. There are no doubt those who will object to the idea that good and bad behavior should be ‘reduced’ from matters of principle to the ‘mere’ contingencies of an empirical science. Certainly, any form of ‘moral determinism’ (such as evolutionary ethics) is inconsistent with the theory supporting values-based practice (see Reading Guide to chapter 1). But the example of pluralism in (natural) action represented by Dr. Petrov in his dealings with Ivailo is a salutary pointer to empiricism as a resource for implementation. By the same token, it requires us to take empiricism seriously rather than hiding behind a supposed in-principle analytical high ground.

All of which is not to underestimate the challenges of implementation faced by values-based practice. We lack as yet even an agreed outcome measure (this is discussed further below, in our concluding chapter). As a resource for tackling such challenges, the change management sciences themselves are after all very much sciences at the cutting edge. The challenges of implementation will no doubt thus require, like other sciences at the cutting edge, the full methodological resources of philosophy as well as of empirical science. But the intimations of success provided by the story of Dr. Petrov and Ivailo, seen through the cultural lens of Balkan pluralism, allows us to approach these challenges more optimistic of success.

6 Conclusions

Through the story of Dr. Petrov and his neighbor Ivailo, we have illustrated the importance of historically derived Balkan cultural pluralism for values-based practice. Faced with the conflicting demands of financial prudence and humanitarian neighborliness, Dr. Petrov came to what is called in values-based practice a balanced dissensual decision about how to proceed. In this, however, he drew not on training in values-based practice but rather on a Balkan capacity for living ‘at the edge of compromise’ developed over several centuries of living under one or another colonial power.

As a learned capacity, Balkan pluralism suggests that the default to monism identified by Isaiah Berlin may not after all be an insuperable barrier to implementing the inherently pluralistic processes of values-based practice. The default to monism thus illuminated, appears to be a barrier not of principle but rather of historical contingency. It is a learned behavior and hence one that can be unlearned.

This revised understanding of the default to monism holds out promise for a number of areas of mental health calling for a full partnership between evidence-based practice and values-based practice. It is important for recovery practice. We noted also its potential relevance (read with other contributions to this book) to contemporary concerns about the disproportionate use of involuntary psychiatric treatment among young black men.