The landscape of poverty

The night before Christmas, Wales had the second worst Covid-19 rate in the world. As three psychologists based in Wales, we are acutely aware that many places across the Welsh Valleys have suffered more Covid deaths per capita than anywhere else in the UK.

Behind the figures lie decades of socioeconomic deprivation that followed the closure of the coal, steel and iron industries. This left a legacy of long-term unemployment, high rates of poverty, a dilution of once tightly knit communities and a myriad of chronic 'adversity associated' health issues including diabetes, obesity, smoking and drug misuse.

Even within this devastated landscape, traditional approaches to addressing poverty and mental health have been individualistic and treated each as independent entities. However, decades of research is now exposing this view as no longer fit for purpose. Psychologists are turning to place-based approaches.

Community level adversity

Our mental health is determined by the conditions in which we are born, grow, work, live, and age, along with the wider set of forces shaping the conditions of our daily lives (WHO, 2014). There is a causal relationship between poverty and common mental difficulties, and people living in poverty will be disproportionally impacted (Ridley et al., 2020).

Recognising the role that our social circumstances play in shaping our psychological health involves understanding that it's about what's happened or is happening to people and not about what's wrong with them (Johnstone et al., 2018). Multiple studies have found that levels of violence, crime, education, psychological distress, and various health problems are associated with place-based characteristics, particularly poverty (Eyerman et al., 2004; Thesnaar et al., 2013; Veerman & Ganzevoort, 2001).

The stresses of living with inadequate access to economic and educational opportunities, or a lack of opportunity itself, contribute to experiences of community level adversity. Trauma is therefore equally created by political, social and cultural processes when, for example, people and communities aren't able to have their basic emotional and physical needs met and are unable to live in safety or are disconnected from each other (WHO, 2014; Compton et al., 2020).

There are specific ways in which individual and community trauma impact our psychological health. These can be summarised as prolonged exposure to humiliation, shame, fear, distrust, instability, insecurity, isolation, loneliness and being trapped and powerless (Psychologists for Social Change, 2015). Chronic exposure to these is detrimental to our physical and psychological health. A focus solely on the treatment of individuals can therefore only ever be one part of the solution to supporting people to flourish and overcome poverty.

As a result, a number of psychosocial ecological approaches or place-based strategies are emerging. The most effective of these respect the complex nature of the task at hand. They recognise that these issues sit within complex networked adaptive systems that aren't linear or predictable. In these systems everything exists in relationship to everything else, and so relationships are the key operating principle.

With such complex problems, practice is continually changing. It is localised to place.It needs to be built together using the principles of co-production, respecting culturally relevant local knowledge, expertise and leadership.

The complex nature of these interactions requires a greater move towards a unified psychosocial ecological approach, with the development of an evidence-base alongside it to better support theory refinement and solution development. To reduce the damaging psychological costs that contribute to intergenerational cycles of distress and disadvantage we must shape our public policy and services to ensure the key indicators of a psychologically healthy society – including agency, security, connection, meaning and trust – are met. We need our current social and health care systems to be delivered in ways that are relationally informed and can address the social determinants of mental health.

Place-based ways of working

A strong sense of community is not new to Wales: it is a country steeped in the importance of community in all its forms. 'Community' as your road, your local rugby club, your school. It has a history of strong, thriving connected communities. For many growing up in the valleys there was a powerful narrative about a sense of belonging felt by those living in the once thriving mining communities.

Life was no bed of roses… it was hard, with high levels of poverty and adversity. But this was a shared struggle, an 'in it together' experience, with the protective whole greater than the sum of the parts. There was a shared responsibility; the shared hand washing of the rugby kit; the lifting of the whole town's spirits on a Friday, payday, bringing with it a collective sense of celebration. These were communities that were not financially rich but had huge social capital. They represented a significant social power in their connecting as equals to confront the shared life struggles and providing meaningful shared solutions. It is no wonder, then, that Wales was the birthplace of the NHS.

Gwent Community Psychology emerged in 2014 with a partnership with a local housing association. The aim was to support those who already had relationships with children, young people and families to offer 'light touch' psychologically informed interventions. Since significant investment in this approach in 2019, a newly formed team has developed partnerships with organisations such as police, housing, families first, youth workers and sports and leisure teams. We have developed what has become known as the three tier model of consultation and offer a range of skill-based activities including group consultation, training, and programmes of group work, reflective practice and staff wellbeing sessions. We are working towards developing ways of working directly with communities and discovering how to remove the organisational barriers associated with this.

As a process-driven and emergent model of service delivery with the concept of 'doing with' at its core, we find it helpful to frame this initial stage of service development as part of a clinical cycle. We are assessing each community's strengths and assets, learning about gaps and planning interventions that fit with our co-constructed formulations. These in turn will be evaluated and fed back in to the overall assessment of each community's wellbeing and resilience.

One example of a more recent partnership is with a different housing association. We were initially invited by a family support worker to offer workshops to a small group of parents, on themes the parents had requested, including children's resilience and children's emotional wellbeing. Through this collaboration the group moved towards sharing stories about their own resilience, and they have decided to write a book together for children to share their stories. For us, the development of community psychology 'work' has often started this way. We are invited as 'experts', because largely that is what expected of psychologists, and through conversations we shift expectations of 'help'. We are willing to listen and learn with humility and respect about what is helpful and what our collaborators can teach us.

We also wanted to go further than this and partner with communities themselves. A local movement towards place-based and collective trauma thinking has allowed our team to begin to explore ways of working alongside neighbourhood partners. We have begun to develop this way of working through 1) building community mental health understanding (i.e. dialogue, critical thinking, and community conversations), 2) meaning making, storying and collective action, and 3) reflection and evaluation.

Drawing on work by Campbell and Burgess we recognise the importance of supporting spaces for dialogue to explore how we understand psychosocial health. These spaces are developed through critical reflection about the local drivers of distress as well as an understanding of the barriers to accessing services or resources. Spaces need to fit with people's cultural beliefs or local support networks and knowledge needs to be nurtured and developed at a local level. Taking a psychosocial-ecological perspective, the underpinning ideas about what we need for wellbeing include having our basic physical and relational needs met, having a voice/active citizenship and being free from discrimination and oppression.

Meaning making

Central to this way of working is 'meaning making'. Social and physical environments must be comprehensive, manageable and meaningful in order to avoid chronic stress. Humans like to recognise and complete patterns, and so we have chosen to draw on storytelling approaches to support this sense making.

Here we have drawn on team formulation and narrative therapy ideas to co-construct stories (formulations) of local issues. By building relationships with each other and developing a shared sense of meaning, we can support communities to heal and build good psychological health and resilience. This process can act as a springboard toward collective action, where communities can engage in processes to seek necessary systemic change to alleviate their distress.

Through this place-based formulation work we have begun to co-develop focused initiatives. In one area of Newport for example, two dominant areas of struggle have emerged through network consultation, surveys and workshops. One is the sense of 'relational security' between organisations, services and residents, i.e. the police, as well as within intimate partner and parent to child relationships. The other is the 'lack of opportunity' for children and young people in terms of safe and green spaces to play and increased exposure to gang exploitation for drug running. As a place-based learning system we have jointly devised solutions to begin to explore how we can increase 'relational security'. For example, a project between the network and Gwent Police will see the 'Heddlu Bach' (mini-police) in local primary schools listen to the community's ideas. Through discussion they would like to improve their trauma informed ways of working by listening to the school children and local residents.

This approach is a continuous cycle, constantly evaluating and reflecting on its position as relationships develop, the story thickens and changes emerge. A constant process of reflecting with communities about what difference this is making is crucial.

Beyond the fortress

As Psychologists working with children and families in Wales, we have become increasingly aware of the parameters of clinic-based child-focused interventions, and we are not alone. A move away from a 'fortresses mentality' and towards place-based and integrated systems of care are essential if we are serious about addressing poverty and health inequality (Ham & Alderwick, 2016).

The evidence base is telling us now that mental health is complex, and addressing these issues is equally complex. These are multi-system issues that require a cross multi-sector response. This includes communities themselves. We all have a responsibility and a contribution to make. Working in ways based on scientific reductionism, slicing problems into unrecognisable parts, can be incredibly frustrating but also obscures and limits access to solutions. It is often said that applied psychologists need to let go of 'being the expert'. Perhaps we should also consider embracing complexity. We don't have all the solutions. We cannot know what the necessary intervention is going to be in unpredictable non-linear adaptive systems – otherwise known as 'people'. Instead, we can use our skills and knowledge to help construct meaning and solutions together in safe spaces, not one person at a time but across whole communities.

- Dr Rhiannon Cobner Consultant Clinical Psychologist, Lead for Gwent Community Psychology
[email protected]

- Dr Jen Daffin Clinical Psychologist, Gwent Community Psychology Lead for Newport

- Dr Sarah Brown, Clinical Psychologist, Gwent Community Psychology Lead for Monmouthshire

References

Compton M.T. & Shim, R.S. (2020). Why Employers Must Focus on the Social Determinants of Mental Health. American Journal of Health Promotion, 34(2), 215-219.

Eyerman, R., Alexander, J.C. et al. (2004). Cultural Trauma and Collective Identity. University of California Press.

Ham, C. & Alderwick, H. (2016). Place-based systems of care A way forward for the NHS in England.

Johnstone, L. & Boyle, M. with Cromby, J. et al. (2018). The Power Threat Meaning Framework. Leicester: British Psychological Society.
Psychologists for Social Change. (2015). The Psychological Impact of Austerity: A Briefing Paper.

Ridley, M., Rao, G., Schilback, F. & Patel, V. (2020). Poverty, depression, and anxiety: Causal evidence and mechanisms. Science, 370(6522), eaay0214. 

Thesnaar, C.H. (2013). Embodying Collective Memory. Scriptura: International Journal of Bible, Religion and Theology in Southern Africa, 112, 1-15.

Veerman, A.L., Ganzevoort, R.R. (2001). Communities Coping with Collective Trauma. Psychiatry, 101, 141-148.

WHO and the Calouste Gulbenkian Foundation. (2014). Social determinants of mental health.