‘It’s about creating environments where people feel that whatever position they are in society, somebody cares and wants to invest in helping them’

How can someone's environment and context shape their psychology?

This is where my interest in social class comes into the picture. The literal material settings – the housing people live in, the urban kind of environment that gives shape to our experiences – can themselves communicate value in society.

I edited and wrote a book in 2018 with Laura McGrath called The Handbook of Mental Health and Space, showing that the environments that people live in can lead to mental health challenges per se because we know that urban environments are less positive for people's mental health. But also, the living conditions that people are situated within do not just lead to poor mental health per se, but also affect the way that the person interprets their mental health. If you're living in really poor housing conditions and your mental health is suffering, how you make sense of that distress is shaped by the context in which you live. It communicates things like how valued you feel, how able you feel to escape from that situation. And we know from the mental health literature – George Brown and Tirril Harris confirmed this in their seminal work in the late 70s – that if people feel trapped, if people feel that they've lost something valuable like their sense of identity, their sense of self, a sense of purpose, then that's really detrimental to their mental health. 

So for me, the setting, the environment – literally the sort of materiality of somebody's living circumstances – contribute to that psychological process. And class is of course, central to that.

You mention George Brown's work in the 70s – could you tell me more about that?

He was a social psychiatrist and Harris was a psychoanalytic psychotherapist. Together they conducted a study with several hundred working class women in Camberwell in London. They wanted to understand what life events and living conditions preceded episodes of depression. Using the Life Events and Difficulties Schedule – a qualitative interview protocol – they measured what had happened to these women 12 months before, with certain women going on to develop depression. 

They found that life events and stress always preceded depression, but there was a further component –  loss. That doesn't mean just bereavement, but loss of a purpose, loss of a role, loss of identity. They were key factors in the development of depression, as was entrapment. The women that went on to experience depression following a stressful life event often had young children, they didn't have a means of working outside the home, they didn't have any independent income. The feeling that they weren't valued could lead to feelings of shame and humiliation. Entrapment was a really important factor here, pointing to environmental factors, to a large extent. 

Brown got me interested in class because he was really bringing into view this idea that depression wasn't just an individualised problem, it was a problem that was born out of real deprivation and an inability to escape from difficult and stressful circumstances. And obviously, that's more acute for working class people, especially working class women who might not have the same access to independent means. He found that those women who didn't have a job outside the home were more vulnerable to those kinds of problems, compounded by their early histories. He found child sexual abuse and trauma came up in the histories of those women whose risk of developing depression was doubled if their current life circumstances were also not ideal.

What I really love about that study was the whole focus on what's happened to these women, the context, the living conditions, the ongoing stresses. 

How have things moved on since Brown and Harris' work? How is psychology generally doing on sort of these things?

I think it's better than it was in clinical and community psychology practice at least, and indeed in psychiatry to some extent in the UK. You know, we're meant to have a biopsychosocial model of mental health these days – whether that actually happens in practice is sometimes debatable, but I think community and clinical psychology is very good at acknowledging contexts. A formulation approach, where rather than just diagnosing you try to formulate an idea of the problem with the client with a whole picture of their circumstances and context in mind, that's a huge shift. And it is kind of paying homage to this idea of the importance of context and lived experience and life history and how they intersect with how we respond to life and relationships.

I would also want to make very clear that service users themselves, their strong voices and activism have had a massive role to play in that development. 

Is your own work looking at some of these things?

We developed the Master's degree, MSc Mental Health and Clinical Psychology, that I direct [at London South Bank University] with experts by experience consultants, and they also deliver an entire module laying out lived experience perspectives. .We treat that as just as important and theoretically coherent as we do other professional approaches.

What I've learned about how things have changed has come directly via that kind of expert by experience channel. On the Master's course, what we try to do on a specific module is show how that lived experience perspective has really sound theoretical as well as empirical foundations. And actually, I get the students to really unpick that… what does that mean, and how far can we take that? For me that that really is an indication of how things have improved and changed.

I'm also Director of Research and Education for the Design in Mental Health Network UK. That network of people comprises architects, designers, experts by experience, and clinicians, and their whole mission is to improve environments for people with mental health challenges. Mostly in inpatient settings, but not just that – thinking about how we can improve cities and communities to better support people with mental health difficulties.

We've also produced a book series called 'Design with People in Mind'. I came up with the idea of producing research materials for designers and architects who want to create something with service users right at the heart of the building project. The idea is that when you're thinking about what the physical constraints might be, for example 'how can we design a door that is anti-ligature, so somebody can't harm themselves or die by suicide as a result of that design?' – we're saying 'actually, architects and designers need to think about psychological safety as well – what makes people feel valued, safe and supported?' 

Going back to your question earlier, about what an understanding of the environment has to offer… right down to the way that we design doorknobs and doors and windows, that can communicate something really important. A lot of patients that we've spoken to have said things like 'you sit in your room and it's like a prison cell'. And what that communicates is 'I'm being detained, punished rather than treated for this mental health problem'.

Again, thinking about social class: you go into some services in deprived areas and the paint's peeling off the wall and the chairs are all broken. To me, that sense of 'we don't give a shit about you' comes across in the materials themselves, in environments themselves. And I think that's really important to get right – it's about creating environments where people feel that whatever position they are at in society, somebody cares and values and wants to invest in helping them through a difficult time and out the other side, towards a better future.

Your own work has used visual methods in these contexts.

Yes. When we tried to introduce visual methods into the NHS studies of mental health service use, with people in secure care and inpatient services, the ethics committees were really not very encouraging of this methodology at first. But we've managed to persuade them that working with people in a more cooperative, participatory way is actually good for the research. So, we've been successful in being able to do around 15 NHS-based studies using visual methods right across the spectrum, from CAMHS [Children and Adolescent Mental Health] inpatients, to communities, to forensics secure services. 

What we found is that visual methods really enables participants to open up about the space and the experience itself. People in an interview room saying 'right, what do you think of x, y and z?' isn't necessarily a very productive way of doing things. Young people are very used to using visual material, and the photo production studies have really opened up their ability to talk about their experiences. It's about starting with them showing us their world. It's them being the author of that world, rather than just the more passive recipient of the researchers' interview schedules.

We've also used drawings with forensic patients where we've asked them about sexuality whilst in hospital. Again, getting people to talk about the issue of sexuality is really tricky. So we invited people to use different kinds of art materials. It wasn't literal representations of sex or sexuality, it was more metaphorical and symbolic. And again, we found that really helpful in organising the interview so that their experiences were the starting point of the conversation. The metaphors, the textures of the visual really helped open up that that level of engagement and conversation.

You also work on memory and a social remembering approach.

Yes, that also feeds into this focus on context. Social remembering is not just what people remember, it's the meaning and the interpretations they bring to those memories, and how that enables them to make sense of who they are in the present.

It's also an ecological approach because it's interested in context. But it's also interested in how the setting, the environment itself, affords us ways of remembering. So the research that I've done with Professor Steve Brown at Nottingham Trent University has been around developing a different kind of approach to memory, which fits neatly with my mental health approach. It's a psychosocial, ecological approach that brings the environment – the setting – into how we understand context, and how people make sense of that context. It's quite similar in some ways to the kind of extended cognition work that goes on in psychology, but it's more from an experiential, qualitative, contextual perspective.

Coming back to the Senate issue, how does your research feed into this year's campaign?

For me, going back to the centrality of context and thinking about where people are situated – often in a hierarchy of relations where some people's voices are valued and other people's voices are not even heard in services – is so important. Class has not even really been acknowledged in that debate around context, and power relations and hierarchies. And yet all the research that we know of, which is growing in volume – Kate Pickett and Richard Wilkinson's work, for example – shows that the the link between social class, social inequalities and mental health is irrefutable in affecting the way we understand ourselves, the way that we even think about our own sense of value in society, which is organised and reinforced via social comparisons and hierarchy. If we are of a lower/working class position, we know that's going to affect our self-esteem, how we understand our ability to communicate our feelings and thoughts, whether we feel ashamed and humiliated by the position we are in. 

I do think it's about how we express ourselves as well, and whether that is valued. We know that, for example, in talking therapies, working class clients don't often have the same access and do not necessarily connect with what is largely a middle class profession. We also know that private clinical practice is unaffordable to most working class people. Often the practitioners themselves are from different, more middle class backgrounds, so sometimes there's a problem with communication and the ability to relate to one another… and we know that in therapy the relationship itself is often more important than anything else. 

On Brown and Harris's point about people's feelings of being trapped in a particular position that doesn't offer them the opportunity or the sense of freedom to move out of something that's difficult for them – that's obviously a problem. And that's intersectional, as well. Of course, it's not just about class, it's about race, it's about gender, disability, and sexuality, all of those really important other positions that we have to acknowledge in building a contextual picture of the person's living circumstances.

Going back to the point I made about professionals though, there is classism that we really need to think about in relation to mental health. Being discriminated against, or having a lack of access to services because of one's class position – that has to be made unlawful.

So when it comes to class, that centrality of context is absolutely vital. But also acknowledging that the living conditions in which people come into the world and move through the system can be detrimental to their mental health. So can classism – and classism is a real form of discrimination – which is why we want to have it included as a protected characteristic of the Equalities Act. The link between social inequalities and mental health is just so watertight, it's so robust. Especially in more unequal societies. 

What do you mean?

Where you get a bigger gap between the middle class and the working class, that affects all sorts of things, including education and mental health. In those societies where that inequality is worse – in the UK or US, for example – it has much greater impact on those at the lower end.

Austerity, for example, supports inequality. It keeps people in their place. It keeps people discriminated against. So that's why I would say that unequal societies unfortunately end up supporting that disparity between the rich and the poor and ultimately that will have a detrimental impact. I'm not saying that people from all social classes don't suffer with mental health challenges – they really do, but one has to be realistic about how those effects are seen more acutely at the lower end. 

More specifically the link between, for example, even severe forms of mental distress such as psychosis, schizophrenia, and poverty… the evidence is absolutely robust. And that's not incidental – in societies where the distressed are supported into employment, supported by the community, they tend to recover more quickly… as Richard Warner, a psychiatrist and cultural anthropologist argued, they feel part of society, they feel valued. We, as psychologists, need to understand that link between poorer mental health, power and inequality and social class in order to provide better services. This is what the Clinical Psychology and Community Psychology sections are writing about doing at the moment.

The Senate is asking for class to be included as a protected characteristic in the Equality Act. Are there precedents in terms of, say, race and gender, to show this has made a difference? 

The evidence is strong, it's clear, and just as much as other forms of evidence relating to race and gender are clear. If practitioners, or educators, or people delivering housing services, or workplaces, discriminate against an individual as a result of their social class, then that should be against the law. And that's what we would hope is that visibility, that legality, would back up and support the kind of evidence that we've been collecting… the detriment experienced more frequently by those of lower working class backgrounds.

Class in Britain is a very specific thing isn't it? In some countries it seems you can rise and fall in class with money, but perhaps less so in Britain. Is class tangibly different in Britain – how do class and economics relate together?

I think they do relate. But one of the things that we're trying to work on as part of our Senate Campaign is how to define class in the first place, as it has to be more than measuring socio-economic status. Class goes beyond economic capital. When the committee last met we were talking about a sociologist called Pierre Bourdieu. He talks about how class isn't just about money. It's not just about total economic capital, it's about cultural capital and social capital, who you have ties with, whether the cultural kind of capital that you acquire via your class background is valued, what your preferences are, your tastes, your modes of expression, whether the dominant society values that or doesn't.

I come from a working class background, and I made my way up through the university system, then got a PhD, and now I'm a professor. You could argue, 'well, that's evidence that it can happen' that you were resilient enough to overcome barriers. I can't stand that explanation because it individualises it. And it's interesting that along the way the remnants of my working class background still feel troubling to me at certain times, and sometimes a real barrier in terms of feeling valued, confident or feeling that I don't fit in or belong in academia or other professional contexts.

The evidence that we're putting together in the reports is really speaking to that psychological and social aspect of how we define and measure class and the impact of class on our sense of self. To look at the impact of class status on our emotions, how we compare ourselves, how valued we feel, our self-esteem. And it's a really complicated picture.

You look at a society like Finland or Estonia where you don't have hierarchies in the education system, you don't have grammar schools, you don't have private schools, funnily enough, everybody rises. Finland is a great example of when you don't have that hierarchy built into the fabric of society in the form of education for example, people thrive more readily. There's that sense that everybody's education is valuable, not just for the few deemed 'bright enough' – or those whose parents can afford a personal tutor or private school place. In the UK, we have grammar and private schools, and you gain social capital by being part of that system, that is then more transferable in certain higher paid professions. And even though people could argue 'oh, well, working class kids can go to grammar school', we know that the proportion of working class kids going to grammar school is really low, and certainly even less so for private school because they can't bloody afford it, or don't have the means to be prepped to apply for a scholarship.

If you have a society that supports or enables certain people at the top end of the system to thrive, then inevitably there will be discrimination and a lack of opportunity for others. 

Is there anything else that you think is important to say on this issue?

A lot of this work has been conducted already – the World Health Organization has acknowledged the importance of social deprivation and social inequalities in relation to mental health. And health services acknowledge it left, right and centre. What psychologists can contribute to is the sense of how that impacts on how we feel about ourselves: right down to how we think, feel and communicate. And that's where I think the real contribution can come, but only if we are thoroughly grounded in context – using robust evidence and sophisticated theory.