Using a Traditional Therapy Model and a Community Psychology

Although there are many different approaches to mental health care, services within England are predominantly designed and organized around a western, individualized and biologically understood approach. Psychiatric diagnosis has come under much scrutiny for not being holistic when trying to understand emotional distress as they exclude psycho-social contributors to distress and overemphasize the need for medication. This essay will attempt to answer the question of whether one can apply principles of Community Psychology within the Psychiatry-led services and the difficulties that may arise for a Clinical Psychologist (CP) in trying to do so. I will be focusing my essay by attempting to critically evaluate whether the traditional therapy model of providing 1:1 intervention or a Community Psychology approach are better suited when working with people who may experience inequality in accessing services and therefore are usually under-represented within talking therapies. This will be done addressing three main areas, therapeutic work with clients, working systemically and thirdly in attempts to develop the CP profession.

The core aim of psychology and psychotherapy is to increase wellbeing with research showing that both internal psychological factors and external social- environmental factors are involved in the development of mental health problems. Current practice, however, of how psychology and psychotherapy are applied has been criticized by psychologists such as Stephen Joseph (2007) for having lost its way and unwittingly become agents of social control. Stephen Joseph suggests that by overemphasizing the psychological and biological factors and ignoring the social-environmental factors, Psychologists are perpetuating social injustice. Liberation Psychologists such as Martin Baro (1994) similarly called for psychology to critically examine itself to be able to support peoples wellbeing and be a force of transformation rather than continually imposing their own view of wellbeing and thereby continuing the oppressive and dominating discourse. Gillian Proctor (2005), a clinical psychologist, has also recently criticized current practice by saying: ...the psychologisation of distress firmly places the cause for psychological ill- health within the individual... Thus deprivation, abuse, oppression and the social and political context of distress can largely be ignored and the practice of clinical psychology can continue to try to mop up problems caused by a sick society. (p.280)

The individualistic approach has been commented on further by Harper (2016) who argued that CP’s have taken a predominately individualistic approach which has prevented them from maximizing the variety of their skills. The individualist approach has limited CP’s to provide predominantly individual therapy (Norcross & Karpiak, 2012), that manages distress once it has manifested. Mainstream individual therapy also tends to locate both the ‘causes’ and the ‘solution’ to distress within the individual, rather than in their environments. This not only legitimizes the therapists’ ground for conducting the intervention, but individuals view themselves as problematic, rather than recognizing the contributing factors arising from problematic environments (Smail, 2005). It has been argued further that, because of this individualistic approach, psychology has under-emphasized preventive strategies and neglects the role that social context plays in the experience of one's distress (Humphreys, 1996, p.193). Martin-Baro, in his attempts to facilitate social transformation, suggested that the problem for psychology is that the solution if offers for socially produced problems often attempt to change individual behavior, while the social order remains preserved, and thereby restrengthening the discourse of problems being caused and located within the individual. Martin-Baro adopted the use of the term “conscientization” with marginalized and oppressed communities, from Freire’s (1971) critical pedagogy which liberation psychologists have described as the process through which individuals develop a greater capacity to reflect, interpret, and act for the promotion of positive change.

Community Psychology offers an alternative that seems to address these difficulties that the Clinical Psychology Profession has come under criticism for. Jim Orford (2008) defined community psychology by saying “ the central idea of community psychology is that peoples functioning, including their health, can only be understood by appreciating the social contexts within which they are placed. It is ‘community psychology’ because it emphasizes a level of analysis and intervention beyond the individual and his or her immediate interpersonal settings. Community Psychology initially borrowed from understandings of the ecology of human development (e.g. Bronfenbrenner, 1979), and later drew from a number of models and theories including those relating to empowerment (e.g. Rappaport, 1987), and liberation psychology (e.g. Montero, 1998). It uses a multi-layered focus (Nelson & Prilleltensky, 2010) with analysis of micro-systems (e.g. a family or social network), meso-systems (i.e. links between micro-systems such as between home and school or relationships between work and home) and macro-systems (e.g. social norms, economic systems, and policies). This multi-level approach can thus differentiate between various influences that could be exerted on people in specific social settings at different stages of their lives. Similar to public health, community psychology also adopts a preventative orientation to promoting healthy lifestyles and environments and grew out of dissatisfaction with clinical psychologists tendencies to locate mental health problems within the individual.

Key principles that community psychologists ascribe by are; Placing importance to peoples social contexts by avoiding placing blame on the individual and looking at the wider ecological systems a person has interaction with including political, cultural and environmental influences (Levine, Perkins & Perkins 2005). Power, empowerment, and disempowerment are central concepts in community psychology in the sense that it recognizes that individuals with relatively little power are more negatively affected in their health (Jim Orford 2008). Power in this sense is societally controlled and arranged which will include wealth, gender, and ethnic group membership and community psychology aim to raise the consciousness of these levels of power and how they are used which may influence psychological functioning. The practice of community psychology also involves working collaboratively with others who are usually those that are marginalized and disempowered. This is usually exercised by moving beyond recognition of power dynamics by finding ways in which to combat inequality and injustice by resisting oppression. One of the ways that community psychology does this is by promoting respect for diversity and to work towards finding ways to redistribute power to achieve greater equality between groups (Jim Orford 2008). Community Psychology is committed to using a plurality of research and action methods by engaging in action-oriented research to develop, implement, and evaluate programs. There are a number of currently debates present within the psychology field in relation to whether it is possible to fully practice in accordance with the Community Psychology principles. The following clinical examples aim to highlight good practice but also some challenges that are present.

How can CP’s apply Community Psychology Principles when working therapeutically with clients?

Mental health services have long grappled with how to serve the needs of marginalized communities. Often viewed as ‘hard to reach’ but yet usually the most in need of support, the number of people from black and minority ethnic communities are disproportionately lower in voluntarily accessed talking therapies and over-represented within nonvoluntary services such as in-patient care under section (Weatherhead and Daiches 2010). Common barriers identified in the literature include language barriers; awareness and familiarity with talking therapies; the stigma of accessing mainstream services and perceived relevance of the therapy (Morgan et al., 2009). These barriers have triggered an influenced the use of a Community Psychology and Narrative Therapeutic within interventions. Narrative Therapy is often seen as a ‘good fit’ with the principles of Community Psychology due to its ability to give meaning and credence to a person’s history and identity. It acknowledges issues of power and oppression, and the place and status of diversity and belief systems which has been supported by literature: “Despite overwhelming evidence that social inequalities such as poverty fundamentally create and maintain psychological and physical ill- health, most mainstream psychological therapies continue to promote internalized and de-contextualized theories and practices....”

“In contrast, narrative therapy highlights the importance of ideological power in human distress, emphasizing how dominant discourses within society in relation to race, gender, and “mental illness” may impact negatively on the wellbeing of clients.” (Kelly and Maloney 2006) One such project, which offers good insight into how CP’s may work with clients in accordance with the Community Psychology principles are The Trailblazers Project. The Trailblazer Project was developed in 2009 to increase access to talking therapies for Black men experiencing mental health difficulties, Funded by the National Delivering Race Equality programmes and facilitated by the NHS BME Access Service’s Dr Angela Byrne, the project aimed to improve rates of referral to psychological therapies whilst also exploring whether CP’s need to be mindful of specific cultural issues when delivering particular therapeutic approaches such as Cognitive Behaviour Therapy. The programme involved 11 African and Caribbean men who attended 5 sessions to take part in The tree of life?1 which is a tool, model, framework for narrative therapy, developed by an African psychologist (Ncube 2006). The project attained good outcomes with participants reporting a positive experience and better understanding of talking therapy and demonstrated a good example of CP’s being able to support Community Psychology principles whilst still working with psychiatry led services. Despite being placed within a system which predominantly delivered 1:1 intervention and within a more Cognitive Behaviour Framework, The trailblazer project was successful in co-producing the design and delivery of the project which contributed to its good outcomes and thereby fighting against the discourse of power being placed within services. The recommendations from the programmed supported subsequent interventions with both the Turkish and Vietnamese communities.

My own experience of working within an adult psychiatry led to service in 2014 with a community psychology approach has given me valuable insight to the difficulties that CP’s might face when trying to uphold the principles of community psychology. My work within The Tower Hamlets BME Access service as an Assistant Psychologist involved delivering interventions within the community to increase access and acceptability to talking therapies for the Bangladeshi Muslim community. Delivered within secondary care mental health services, and working within a community with a large Bangladeshi community (32% in Tower Hamlets) and with the highest percentage of Muslim residents in England (35% compared to a national average of 5%), the project ‘Faith in Recovery’ was run in collaboration with a community mental health service with the aim of making talking therapy more relevant for the clients and in a culturally sensitive way (Mustafa and Byrne 2014). The intervention runs across 8 weeks with 10 participants who contributed to the design of the sessions. Islamic ideas of wellbeing were incorporated into the tree of life and an imam was invited by request of participants in order for them to raise questions about religious ideas about mental distress. The sessions were evaluated through a focus group where members expressed interest in further groups being run in a similar fashion. Members spoke of the importance of peer support and contributed to the success of the group as being due to it being run within a community, and a ’safe’ setting (Mustafa and Byrne 2014), and with them contributing to the design and delivery according to how they wanted to develop their understanding of emotional distress linking directly into Community psychological principles of power, empowerment, working collaboratively, and with social context in mind.

Despite the success of this project, and the clear commitment to reducing ethnic inequalities made by the National Service Framework and NHS Plan for mental health (Department of Health, 2005), the service was unsuccessful in retaining my Assistant psychologist post to continue the work leaving only the lead psychologist needing to continue the work on a part-time contract. This is a familiar struggle that many Community Psychologists face and keeping the possibility of this in mind we delivered the intervention in line with the community engagement model (Fountain et al, 2007) which seeks to collaborate with voluntary sector staff with the hope that expertise will be shared between both parties and that they may be able to continue running interventions well after involvement from CP’s. The Critics of Community Psychology further criticize community-run projects by stating that they run the risk of unintentionally being agents of social control because they are regulated by the government policy and essentially a provider of medical services (Parker 2007). Other projects have sought to combat these difficulties by placing themselves strategically with the charity sector. Music and Change, founded by Charlie Alcock, works with the often underrepresented young people living in socially deprived estate by engaging them in innovative means of accessing talking therapy such as ‘street therapy’ which is focused on building trust and rapport with young people in informal ways (Zlotowitz, Alcock & Barker, 2010). However, these projects still come with the regular challenge of having to find funding which will continue to sustain them and often can prove to be more costly requiring more time and effort for the longer period at which a CP may need to engage for authentic community partnership working which.

The Social action psychotherapy model was developed in the 1980’s by Sue Holland, a feminist psychotherapist with roots in community action, who was working with a group of women on the White City Estate in London. She developed an approach that began with individual psychotherapy, progressed to involvement in groups and then to collective social action. In this process, mental health was reframed: instead of being seen as private individual distress in mainly biomedical terms, it was seen more in a societal context (Holland, 1988). Her work with African and Caribbean highlighted the strengths communities can have in becoming a collective against struggling with issues such as racism. Her work, which is frequently cited as influential by clinically oriented community psychologists in Britain, drew on both psychoanalytic theories and on the idea of conscientization from Freire (Freire, 1972). Her work has also influenced other work by Dr. Angela Byrne in working with women from the refugee and asylum community who have been affected by HIV. The Assure women's project offers opportunities for engagement at each of the three levels suggested by Sue Holland (1992) offering individual therapy on a personal level, opportunities to come together as a group on the interpersonal level where participants can develop collective strategies and then also invites women critical perspectives on psychology by supporting participants to get involved with service design and delivery and calling for social action for the rights of migrants.

To summarise, CP’s utilize a number of their skills in therapy when working in accordance with the Community Psychology principles. Clinical Psychologists are able to deliver group interventions, co-designed and collaboratively delivered with voluntary sector organizations, with the aim of work continuing through the sharing of expertise with community workers. CP’s are also able to support dialogue within therapy on a personal level which demystifies psychology and encourages people to self refer to groups, social action schemes and also survivor groups which aim to influence change within services and offers opportunities for clients to voice the importance they may place on social and political contexts which may be influencing their distress.

With the change at the core, many of the above examples are to be more ameliorative orientated rather than being balanced with transformative. Nelson and Prilleltensky (2005) distinguished between the two: Ameliorative interventions are those that aim to promote well-being. Transformative interventions, while also concerned with the promotion of well-being, focus on changing power relationships and striving to eliminate oppression. Nelson and Prilleltensky (2005) go on to say that most forms of critical community psychology action are ameliorative and that although the ameliorative action is good, they argue for more emphasis on a transformative change to promote social justice and create long-lasting, sustainable change (Kagan et al, 2011). One such way to achieve transformative change is for psychologists to disseminate learning and raise awareness through research which will be discussed next. How can CP’S apply Community Psychology principles whilst conducting research? An important aspect of a CP’s role encompasses the scientist-practitioner commitment to conducting research

How can CP’s apply Community psychology principles whilst working systemically?

• Beyond the therapy room
• Psychologists against austerity
• Power threat meaning framework
• Community psychology festival
• DCP - community psychology section
• Psychologists against austerity
• Research

Social Action Psychotherapy

CMM

Context and discourse map

Discussion

• Becoming the political
• If able to - community-based interventions
• Use of language
• Importance of raising awareness
• Commitment to social action - influencing public policy

Being the change that we want to see

The tree of life provides a safe space, both emotionally and physically to share and explore each other’s ‘narratives’, or stories. It is a visual model, created from roots to leaves across past and present. Its value in narrative therapy is a primary focus on the person, not illness or symptoms, through creation by the client (Margaret Calin, 2009).