The purpose of this paper is twofold. Firstly the government have just issued a National Service Framework for Mental Health in which one of their themes is the connection of mental health promotion to the policy initiative 'against social exclusion'. Part of this is explicitly about mental health strategies aimed at neighbourhood level. Secondly, coming at the same topic areas from the other direction, part of Radford and Hyson Green (in Nottingham) has been designated as a programme area for the government's New Deal for Communities and targeted for special support aimed at dealing with social exclusion. One of the policy areas to be worked on in this respect is mental health. This paper is written to inform both processes in regard to how mental health issues can be approached in relation to neighbourhood development and, in the process, how community care can be connected to community development.
The geography of mental health
There is a "geography of mental health" in so far as mental health problems do get concentrated in some areas more than others. The reasons are partly that mental health problems tend to be lead to poverty and unemployment so that people with mental health problems drift to living in the areas which are considered "less desirable" where cheap rented accommodation for people on benefits is concentrated. At the same time mental health problems can be said to be caused or exacerbated by the environmental and social features often found in these very same neighbourhoods. In places of "multiple deprivation" the concentration of absolute and relative deprivation, the fear of crime, high levels of intimidation and vandalism, demoralisation caused by poor housing, heavy traffic leading to social isolation, all create stressful environments in which to live with psychologically toxic effects.
From this it might seem that a common sense approach to dealing with mental health in deprived areas would be to identify the people with diagnosed problems, as well as to survey the things about the neighbourhood which are causative of mental health problems, and then to focus a programme on these people and these problems. However this seemingly straightforward approach may not only not work it may actually turn out to be counterproductive.
Projects that go 'beyond the diagnosis'
Identifying people with problems and setting up services focused exclusively on them and their problems can trap them in their problems - while they are using these services they are, by definition, there because of their diagnoses. Their relationships, the settings and activities come to be premised upon their diagnosis. Although sometimes helpful initially, specialist services can easily lock their clients into lifestyles of dependency, stigma and the isolation that comes from being identified by family and neighbours as a "problem person. After a crisis has passed and a person who has had psychiatric problems is trying to rebuild their life they need to be able to (a) form relationships with non diagnosed people in (b) ordinary settings in which (c) they can feel they are making a positive social contribution and/or are active in ways which shows them to be capable and competent people. It is in such relationships, settings and activities that people can start to live a life "beyond their diagnosis".
"Beyond the diagnosis" projects must focus on something other than mental health - that way people can develop their own interests and skills, the settings and the projects focus not on what is wrong with people but what is positive about them and, moreover, it is possible for non-diagnosed and non stigmatised people to get involved for reasons other than what are condescending do-gooding motivations, thereby promoting social reintegration. If people are no longer, or never have been, in need of direct supervisory care it is arguable that, other than a watching brief, the less the official mental health services are involved the better.
The stigmatisation of neighbourhoods
Just as one should question the idea that services should focus to sharply on people with mental health problems so one can question the idea that the mental health policy in community development programmes means directly identifying and targeting neighbourhood sources of "psychological toxicity". It might seem like common sense to survey deprived districts to find out what makes the residents in them unhappy, stressed and broken up - but the opposite viewpoint has some plausibility. Once a district has become the focus of special attention and a programme as a "problem neighbourhood" it is likely that it will already have been surveyed and talked about negatively quite enough. Yet another survey to reveal where the problems are might do more harm than good. For what this does, in the act of finding out even more, is to further magnify the bad reputation of the neighbourhood and, in this very act perhaps, make things worse. If one looks for unhappiness one can always find it. Even if one surveyed more affluent neighbourhoods one would find a sea of unhappiness among the worried well. One has only to read Oliver James's book "Britain in the Couch" to see that. Indeed James uses misery and psychiatric symptomology in the Royal Family to illustrate his thesis that wealth, power, status and happiness do not necessarily go together.
A recurring theme in psychotherapy is the tendency in human affairs for the world to confirm people's expectations of it. If you think the world is a threatening place you will see threats in every situation, prepare your self defence moves and people will respond to these defensive moves in ways which will confirm your view of the world as threatening. In this case if you spend all your time analysing what makes you and your neighbours miserable you will find even more to be miserable about than when you started out. You will not only end up feeling a failure for living in a neighbourhood full of socially excluded people, you will probably end up feeling resentful and paranoid of your neighbours too.
Concentrating on positives
It is plausible to argue that what is needed is something that concentrates on positives. Even in the most deprived and demoralised places one will find people and features that are positive. At a recent meeting organised by the Partnership Council in Hyson Green I heard people saying what they liked about living there. They were sick of being told what a terrble place it was by people who claimed that they were trying to be helpful. They thought it might be helpful to do surveys of what is good about the place and start building on that.
A good alternative starting point would be to find what skills people have got in the neighbourhood, what they are already doing in the way of formal and informal community activities and what they want to do - and then organising programmes of supportive of those things. Tony Gibson, who developed the neighbourhood development tool "Planning for Real", has suggested that just listing all the things that people in a neighbourhood can do can be very encouraging. Of course it is possible to do more than list skills - it is possible for people to display their work - both to each other and, in a networked world, in Internet.
Activity relationships do not need to be focused around income generating paid employment - on the contrary they can focus on an extra-employment sphere which make people's home life, their habitats, their hobbies, their recreational pursuits, their relationships more effective, socially more meaningful and horizon widening.
Students and ex-students - waiting to begin life....
One aspect of deprived areas that is perhaps worth remembering is that many hard up students live in them. Some, who drop out of their studies, or who finish their degrees but cannot find an appropriate next step for themselves in life remain in their cheap rented accommodation. Many highly competent, very talented people, with a lot to offer are distressed, at sea, demoralised, disorientated to find that their lives have got stuck or taken a wrong turning. They cannot find a way to extricate themselves from their current predicament - and yet as people they can metamorphose quickly in appropriate settings revealing a whole range of talents and abilities if the right infrastructure of non condescending support is put their way. Often this is best not, first of all, in employment. If you go for counselling support into setting up your own business you will be told that the right reason for this is that you want to be your own boss, that you want to be independent. There are quite a few young people out there who are very capable of organisational team-playing but who are too independent minded to become junior employed cogs in larger employing machines. Moreover their personal values sometimes incline them better to community, social and environmental activities than to corporate money making. They are willing to lend their hand to things but only if they can find activities that they can believe in. Then there are those whose lack is precisely that they do not have anything to believe in. It is worth mentioning in this respect an anecdotal conversation with a GP in the St Anns areas that I recently had. He told me that he could think of several regular visitors to his surgery who came with a variety of ailments but, if he were pressed for a proper diagnosis of their problems, he would say that they were really lacking something meaningful to be involved with, that they could believe in.
What are mental health problems anyway?
What are called "mental health problems" are often no more than exaggerated versions of what happens to everyone at some time or another. People are having mental health problems, in the common understanding, where their experiences - their thoughts, emotions, and actions - are not understandable to those around them and they are not coping and/or exerting a disruptive influence in the lives of other people. I believe we should be very careful when we use diagnostic words like 'hallucination', 'mania', 'delusions', 'confusional states' etc. because these are only more powerful versions of what everyone experiences (day dreaming, excitement, wishful thinking, panicking, impulsive behaviour, flashback memories, absent-mindedness, looking for 'signs' to predict the future etc.). The use of ordinary language would help us discover that everyone experiences these mind states - and reminds us that if people are experiencing such things it may be because their past and present lives are, or have been, traumatic, chaotic and distressing. As I have argued elsewhere if we are able, as individuals, to give structure, meaning and direction to the patterning of our lives, if we can manage it, we will be OK. Mental health is the state of morale and orientation, the mental framework that allows individuals to manage in the contexts they find themselves. For most people this translates to more or less adequately managing their relationships, in their habitats, within their income and work commitments, in a way that enables them to maintain the health of their bodies.
Mental Health problems arising out of multiple deprivation
People suffering from multiple deprivations, however, may lack a lack a routine pattern of (employment) commitments in their lives and thus suffer a chronic lack of calendar structure (while elsewhere in the out of balance community others try to cram too much into their diaries and suffer from chronic deadline pressures and scheduling stress!). Poor and isolated people may have no relationship pressures to keep where they live tidy and clean in arrangements for joint living - nor the skills or motivation to maintain a well organised habitat. Squalid domestic arrangements then undermines their self esteem, as well as puts off potential relationship partners. (It is remarkable how many young men set up their own homes without the practical skills of cooking, cleaning, house maintenance, buying their own clothes, laundry etc. They then end up living in poor quality housing with inadequate domestic facilities where these things are difficult and expensive in any case. ). Further causes for loneliness are a chronic lack of money and future prospects. Without relationships the sources of emotional warmth, trust, intimacy, support, shared purpose and meaning become chronically absent with long term psychological effects. People living in poverty may have insufficient purchasing power to be able to sustain life's practicalities over the long term and thus maintain their physical health. Only when you have lived in a very cold house or flat in winter terrified by your fuel bills can you fully understand cold as a source of mental health problems. As you wake freezing and alone in the middle of the night it can be impossible to distinguish the sensation of fear from the sensation of being very cold.
Psychosis arising from confrontational isolation - the relevance of social inclusion
From the point of view of the mental health professional it can often look as if the degradation, loneliness, poverty are all the results of the mental health problem. Actually, however, the better way of seeing things is often the other way round. It is hardly surprising that many people without money, domestic skills or relationships trapped in the web of multiple deprivations are so frequently demoralised, fearful and sometimes angry and bitter. The problem can then be that for some people the anger, fear and bitterness will drive them further into an isolation, into a state of deep social exclusion in which full blown madness becomes virtually a foregone conclusion. (As I have argued elsewhere psychosis can be seen as the inevitable result of confrontational isolation. It becomes impossible to reality check when one withdraws, and/or is driven away from others, in a hurt emotional state. The emotions in this state drive along the thought processes in an emotionally associative style of thinking rather like the quirky associations used in advertising. Such confrontational isolation often throws one back to the feelings of infancy when one first experienced or feared abandonment and total vulnerability and into childhood ways of behaving - some psychotic fantasy behaviour being rather akin to play).
Inclusion in a sustainable or non-sustainable future?
The connection of mental health promotion with the social inclusion agenda is therefore spot on. It is isolated, rejected and stigmatised people who go mad and then find it hard to recover. They may suffer agonies of chronic boredom punctuated by periodic terrors - which is the fear that they will one day die before they have ever really existed, before having a life with the ordinary satisfactions: social acceptance, a comfortable house, sexual love and so on. However we must beware of what we mean by "social inclusion". Many people who have been stigmatised and driven into social exclusion are angry, bitter, and distrustful. They have usually had good cause to be and, as I have indicated already, there are many who do not want to rejoin a social mainstream of happy shoppers out with their families who spend their evenings watching TV or having bridge parties talking about the values of their houses. A very large portion of the chronically under active are not at all allergic to work - but they are allergic to being bullied by clerks at the department of employment and sent for jobs where they are condescended to by corporate personality types who have sold their souls to the meat industry, the arms industry, nuclear power or one of the other institutions of unsustainability. A couple of years I attended a conference for the empowerment of homeless people organised by Groundswell in Sheffield. It was noteworthy how sustainability, energy efficiency, recycling and the like had been taken on board in a practical way by homeless people far more than among most corporate hierarchies. The homeless people did not want to be socially included in the mainstream as it is now - empowerment for them meant challenging and changing that mainstream. There was an awareness that the mainstream is actually unsustainable.
In his book "Britain on the Couch" (Arrow Books 1998) Oliver James describes a huge amount of current misery as arising from people making unfavourable comparisons between themselves and people who are more "successful" in income, status and consumption terms as society has become more competitive and consumption orientated. If social inclusion is taken to mean the ability to keep up with the lifestyle of the Jones as advertised on TV then we can forget all efforts towards social inclusion as being totally futile. The first will be last on matters of sustainability because the Jones are money junkies tied into a competitive lifestyle who need social inferiors to remind them what marvellous people they are.
In any case there are compelling ecological reasons for social inclusion to be thought of differently. Social inclusion cannot be purely defined in conventional employment, consumption and income terms because current consumption and income arrangements are actually socially and economically unsustainable. The Wuppertal Institute, a ecological research establishment in Germany, was commissioned by the German Friends of the Earth to define what sustainability would mean in the middle of the next century and concluded that there would have to be a 80-90% reduction in the use of non-renewable energy and raw materials. This is a 2-3% per annum reduction over the next 50 years. Any social and economic strategy that does not take this on board is practically irrelevant. Such a large reduction is only achievable by thorough going changes in the way people organise their domestic and community life. It requires people to find their welfare more in non material things - through expressions of their creativity rather than through ownership and consumption. A different way if improving lifestyle - for example through new activity relationships that overcome isolation - are needed. Much energy and raw materials can be saved if people become more self sufficient in the provision for themselves of some essentials - e.g. Growing at least some of their own food in community gardens. Another helpful thing would be for people to save energy and water at home. It requires too that people share many consumer durables, facilities and resources more so that it is unnecessary for everyone to own their own. In short more efficient homes and neighbourhoods is the logical place to start to meet the Wuppertal targets, working with those very people who, as shown before, are struggling to survive.
In conclusion
An eco-psychological approach to community development recognises that mental health problems arise when people are stressed and isolated in organising the practicalities of loving and living in inefficient habitats, with insufficient income and no purposeful activities to structure their days. By focusing on what skills people have and bringing them together to help and support each other it is possible to make a big difference to people's quality of life, overcoming isolation and building up people's self esteem and social insertion. A good theme for this is in ecological habitat renewal and various domestic skills which can be connected to the ecological agenda in various ways. In Nottingham Ecoworks exemplifies this way of working and for some time has given people an activity network which is deliberately not intended to be directly "psycho-therapeutic". However there are other projects in Nottingham that are valued by their users. The Hyson Green Eco-Sewing and Craft Group has never had a professional therapeutic input either and concentrates on craft, art and sewing skills in recycling fabrics and other materials. Other projects also exist which, although not focused on ecological themes exemplify possibilities for working away from therapy models - Creative Solutions is an example. Such projects do not need to be explicitly about mental health indeed, in many respects, it is better if such projects are not about mental health at all - but are "beyond the diagnosis" giving otherwise stigmatised people a chance to show what they can do, alongside non-stigmatised people in a way that allows them to escape their identity as mental health service user, patient or client.
This does, however, raise problems in regard to funding. If one wants to set up "beyond the diagnosis" projects then who exactly is to fund them? The mental health services might argue that they should be funding services focused on people with a diagnosis. When the positive mental health effects are to be had because they are indirect this does raise a question as to who should be putting in the money. As the focus in these projects is on other things - environment, energy, gardening, habitat - we have been able to get non mental health sources of funding up to a point - but with the downside that funding has to be renewed every three years in the new funding programmes. As a development worker a bit of me wants to argue now for mainstream funding - but I would rather that that this came from a pot of money that was itself for multifunctional projects and not solely from a mental health services financial pot. One thing is sure, without mainstream funding for what I feel is now a proven idea, projects like Ecoworks will only get so far and myself as a development worker will get caught on a treadmill. as "redevelopment worker" having to seek funding every three years to keep things going. This will entail being unable to move on enough to set up and support other variants of the "beyond the diagnosis model" - in my case being unable to give the amount of support that I would like to do to the Eco-Sewing and Crafts Group and working more, as I would like to, in Hyson Green (rather than with Ecoworks in St Anns).
In the voluntary sector we are being asked more and more "to work in partnership". Perhaps it is time that the mental health services worked in partnership with the parts of the public sector responsible for community development, the arts, environment pooling at least a part of the specialist budgets to create new funding sources for innovative approaches down on the ground.
Brian Davey
Voluntary Sector Mental Health Development Project
Ecoworks, International Community Centre,
61B Mansfield Road, Nottingham, NG1 3FN Early October 1999
References: The approach to mental health taken in this paper is discussed in my article "Meaning, Madness and Recovery" in Clinical Psychology Forum 103 May 1997 pp19-26 and My article "Mental Health and the Environment" in "Care in Place" Vol 1 No.2.
There are several articles on my web site which explore different aspects of the above themes:-
A Strategy For Losers
© BRIAN DAVEY