Can we sustain the magic?

As a clinical psychologist working primarily from a therapeutic perspective, I have always kept a second string to my bow. In the 1980s it was community psychology and more recently it has been community engagement. Experience tells me these three perspectives are vital to achieving social inclusion.

I first became interested in social exclusion as a voluntary detached youth worker. I spent a summer with the 'problem' children of the local council estate. I was shocked at how deprived these children were and how they survived. They had little parental support, no hope of anything better and few aspirations beyond immediate survival. Keen to understand my strong reaction to these children's lives, I read Street Corner Society (Foote-Whyte, 1993). This was one of the first books that used a method known as participant observation. It struck a real chord with me and helped me value my feelings as part of the key to understanding exclusion.

At university I was inspired by Paulo Freire (1972) who helped illiterate, oppressed men in Buenos Aires know about and change their situation, by using Marx as their text. The idea that understanding the wider causes of exclusion can give excluded people the strength to address it was very appealing and has stuck with me. During my clinical training, Sue Holland's (1988) consciousness-raising work enabling depressed women on the White City estate to help themselves, reinforced this idea.

I was hopeful that subsequent government programmes drawing on these approaches – harnessing individuals' and communities' hidden resources to achieve inclusion – would have a widespread impact. I was disappointed of course. Somehow these programmes failed to replicate what had seemed like 'magic' in the pioneering projects. I wondered what the failure of generalisation was about.

Much later in my career I was conducting in-depth interviews with mental health service users about their take on exclusion and recovery (Davis, 2000) when the same 'magic' seemed to crop up again, this time making the difference between recovery and staying trapped in services. My interviewees told me of years watching their identity gradually eroded by the views and behaviour of others and their own reluctant acceptance of a new but false identity as a failed pariah or passive recipient. Some eventually questioned their 'bargain' with society and services, resulting in what one called 'the bounce' – an awakening.

I was told the 'bounce' included the realisation that external not personal factors were largely responsible for their plight and how this kick-started their recovery. Sadly, I was also told of many friends who did not 'bounce', leaving them excluded and dependent on mental health services.

I wondered why some people 'bounced' and others didn't, just as I had wondered why some community development programmes worked and others didn't. What did they have in common? Successful bounce stories (see below) involved real collaborative relationships; for example, with a therapist through counselling or a community through psychosocial rehabilitation programmes such as the Clubhouse model (see www.iccd.org). Their common ingredients seemed to be the unshakeable commitment by 'workers' to respecting 'service users' and their unswerving belief that real benefits would come from working conjointly with people often vilified by society.

Reflecting on my earlier question about the failure of generalisation in community development programmes,  I formulated a hypothesis that the critical values and service principles needed for real inclusion, which were so clearly evident in Freire and Holland's pioneering work, were by definition hard to replicate in wider government-sponsored programmes. By being officially 'prescribed', the all-important relationship ingredients of sense of ownership, passion for the task, collaborative inquiry and genuine discovery can get lost. I believe understanding this is crucial to answering the question of the moment: What can now be done to reach those people who remain deeply excluded and who are the hardest to reach?

What needs to be understood, then, to promote and sustain working collaboratively on a wider scale? Two examples from my recovery research illustrate collaboration's value. Firstly, a young woman who believed she was the cause of the death of many around her and was a victim of childhood sexual abuse. In her many counselling experiences she repeatedly reached a point of such emotional intensity that she was told she was not strong enough and therapy should stop before it caused harm. Fortunately, in her last therapy she was met with a different response. Her counsellor, rather than using professional power to cease therapy, asked my interviewee what could be done to get over this difficult period. After discussion it was agreed together that the client would take brief holidays from therapy at these points and return when ready to continue. After several periods of intensity and holidays the collaboration bore fruit. In time my interviewee no longer believed she caused the death of everyone around her and she returned to work. One key aspect of this process was the included person's (the counsellor's) preparedness to accede to the power of her client's own solution.

Secondly, a successful trainer in the City lost everything following a manic episode. He was sent to a day centre for people with depression. He gave up after many years, as he just didn't fit in! He then discovered a Clubhouse where his talents as a trainer were welcomed into a community where the service was built on the skills of its members, and he 'bounced'. Since then he has championed work for people with mental health problems. Although his job remains within the mental health system his recovery coordinator role allows him to share the value of his experience, his 'bounce' and how this can be promoted in others through collaboration.

These stories illustrate a resolution to the dilemma identified by community psychologists (e.g. Melluish, 1998): community psychology has limited capacity to 'empower' when the onus for social change is so often (mis)placed (solely) onto (changing) people with the least resources. The difference in the examples above is that something vital was transacted between the representative of the included class (e.g. the counsellor or Clubhouse staff) and the excluded person. My research participants said it was people's respect for who they had been, were currently and could be in the future that allowed them to bounce. They felt those people around them who were prepared to offer hope and to understand their struggle to escape victimhood, who openly acknowledged society's part in exclusion, who shared their power and resources and most importantly kept going when their own energy for change was flagging facilitated their 'bounce'.

I have experimented with the 'magic' of collaborative inquiry, collaborative discovery and the co-creation of support (services) using combinations of individual work, community psychology and community engagement, but it is not to be tamed. I would argue that the real task is the creation of contexts that support practice values and service principles that are themselves inclusory. To achieve this, people in society who have the power to exclude must firstly understand and value the identity and experience of excluded people and secondly, work with them and society to share hope, promote choice and create opportunity. Psychologists can assist by supporting practitioners, especially universal service workers, to develop and crucially maintain collaborative relationships. This is not simple, because these kinds of relationships only survive in strongly supportive environments. Attempts to bring these about through service redesign and policy development (on prescription as it were) will only work if we include the freedom to engage in the psychological work required to establish creative relationships. The most recent term used to describe this collaborative process has been 'co-production' (Hunter & Richie, 2008). 

In my journey from detached youth work to experienced professional, I have been privileged to learn first-hand from excluded people what society must do to enable them to 'bounce' back as active citizens. Inclusion is about both empowerment and the removal of social barriers, but to succeed we must be prepared first to accept that exclusion itself undermines and diminishes our sense of self, social identity and our wider human values, and then start acting inclusively.

Commentary
Elizabeth Holford – Member of the DCP Service User and Carer Liaison Committee

It warms my heart to read such an open and committed account of a clinical psychologist's quest to understand. It captures precisely what worked for me.

With a diagnosis of schizophrenia, I spent many fraught years fighting to secure the employment, family and community life that I had worked hard in my youth to achieve. Eventually referred to a clinical psychologist, I encountered 'magic'. Like Fabian, I wondered why this person succeeded where others had failed. Like Fabian, I identified humanity and willingness to work in a spirit of genuine inquiry, and courage to dispense with the straitjacket of accepted 'wisdom' and the excluding power of diagnostic labels. 

I agree with Fabian that making magic mainstream requires supportive environments. But the barriers to this are more than just social – more than just changing 'exclusory' attitudes and policies. For, as in Narnia, beneath the magic, 'there is a magic deeper still' – and very mundanely, this deeper magic is money. Money to afford time and skill.

Collaborative relationships require skilled practitioners with time to engender trust. 'Magic' demands of the practitioner the confidence to spot the often fleeting point at which 'bounce' is possible and to muster every shred of humanity and learning to make it happen. This is a tall order. We can sustain the magic if society can stomach the bill.

References

Davis, F.A. (2000). Revalorisation: What experiences, resources and supports contribute to successful social reinclusion and a return to valued social status for people with severe and enduring mental illness. National Library for Health. York Hospital NHS Trust.
Foote-Whyte, W. (1993). Street corner society. The social structure of an Italian slum (4th edn). Chicago: University of Chicago Press.
Freire, P. (1972). Pedagogy of the oppressed. Harmondsworth: Penguin.
Holland, S. (1988). Defining and experimenting with prevention. In S. Ramon & M. Giannichedda (Eds.) Psychiatry in transition: the British and Italian experiences. London: Pluto.
Hunter, S. & Richie, P. (Eds.) (2008). Co-production and personalisation in social care: Changing relationships in the provision of social care. London: Jessica Kingsley.
Melluish, S. (1998). Community psychology: A social action approach to psychological distress. In P. Barker & B. Davidson (Eds.) Ethical strife. London: Arnold.