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Murray, M. (2012). Psychologie de la santé communautaire, des arts et de l'action sociale

[Community health psychology, arts and social action]. Bulletin de Psychologie, 65, 33-40.

Michael Murray

Keele University

U.K.

Contact:

Dr. Michael Murray, Centre for Psychological Research, Keele University, Staffordshire, UK

ST 15 8DF. Email: m.murray@keele.ac.uk

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Community health psychology

Abstract

Community health psychology is an approach within health psychology that has evolved

over the past ten years. It draws its inspiration from complementary strands within critical

psychology, social activism and public health. It is concerned with working with groups and

communities to transform their living and working conditions and to enhance the quality of

their health and social wellbeing. The aim of this article is to trace the development of this

approach and to consider the particular contribution of the arts to enhance local social

action and broader social change.

Keywords: Participatory action research; Arts; Public health

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Community health psychology

Community health psychology seeks to develop a more social and political approach within

health psychology that develops ways of enhancing health and wellbeing through various

forms of social action. This approach draws attention to the importance of the broader

societal context within which health and illness are located. It stresses the importance of

the interconnection between critique and action coupled with a reflexive stance to our own

research priorities and practices (Campbell & Murray, 2004).

This approach is part of the broader critique of health psychology which has developed over

the past 15 years (Murray, 2004). Health psychology can trace its formal establishment back

to the 1970s - a period of retrenchment in the capitalist world with the election of

conservative governments in many western nations. As such it was informed by the

individualism and the victim-blaming ideology that was pervasive at that time as

governments placed greater responsibility for ill-health on the individual. However, health

psychology had much more radical forebears as is evident in a brief review of influential

contributions in the 1960s. This was the period of sustained social and political revolt

throughout Europe, North America and the former colonial world. This political revolt was

echoed within the psychology establishment. For example, William Allbee was elected

President of the American Psychological Association in 1969 with a radical agenda

connection social action with improvements in psychological health. As he argued at that

time:

‘We must realise that the terrible suffering that exists in our society among the

disenfranchised, the poor, the havenots, can only be remedied by direct

confrontation with the establishment, by the socialisation of our care-delivery

systems, by the development of adequate tax-supported public facilities, staffed

with competent BA-level interventionists using social models which can only be

developed as creative people find out about the real problems ... The times are right

for revolution!’ (Allbee, 1969, p. 7).

Such a call energised many psychologists, especially those working in the field of mental

health, to explore new ways of practicing. They were dissatisfied with the individualist

assumptions and ‘scientist-practitioner’ model favoured by clinical psychology that sought

to emulate the power and methods of medicine. In the United States, this move led in the

1970s to the development of community psychology based on a more community-activist

approach to health intervention. This turn to the community was premised upon an

awareness of the social basis of mental health and the need to work collectively to challenge

social oppression in its myriad forms.

Conversely, the emergent health psychology focused on individual change. Matarazzo

(1980), who was very influential in defining the new discipline, argued that its aim was to

‘aggressively investigate and deal with the role of individual behaviour and lifestyle’. Rather

than developing social and collective strategies to ‘deal with’ structural inequalities health

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psychologists turned to the evolving social cognition models of individual attitude change.

The theoretical approach developed by Fishbein and Ajzen (1975) became the dominant

orientation within health psychology. This approach drew much if its inspiration from the

information-processing models that had become popular within mainstream cognitive

psychology at that time. As Fishbein and Ajzen (1975) stated in their foundational text:

‘Generally speaking, we view humans as rational animals who systematically utilize

or process the information available to them. The theoretical structure or

conceptual framework we have adopted assumes a causal chain linking beliefs,

formed on the basis of available information, to the person’s attitudes, beliefs, and

attitudes to intentions, and intentions to behaviour’ (p. vi).

Although their formulation of the relationship between attitudes and behaviour included

reference to social norms it was very much an individual change model that made limited

connection with the broader social world. The following 30 years has witnessed various

attempts by health psychologists to refine and extend this attitude model but the basic

assumptions are similar to the original formulation.

However, more recently there have been various attempts to reconnect health and

community/social psychology and to explore new forms of social activism designed to

promote health. The challenge to the social cognitive models was initially on

methodological grounds. Health psychology researchers became frustrated at the

quantitative methods of investigation and there has been increasing interest in qualitative

methods (Murray & Chamberlain, 1999). Some health psychologists have begun to reach

out to more activist forms of social inquiry – ones that are not premised upon information

processing and behaviour controlling assumptions. In particular, they have turned to

various forms of community-based participatory action research. As in community

psychology, in general, there are different orientations within this approach. The more

accommodationist orientation focuses on processes within the community, while the more

critical orientation aims to connect intra-community processes with the broader socio-

political context. A primary aim of the critical orientation is:

‘to promote analysis and action that challenges the restrictions imposed by

exploitative economic and political relationships and dominant systems of

knowledge production, often aligning themselves with broad democratic movements

to challenge the social inequalities which flourish under global capitalism’ (Campbell

& Murray, 2004: 190).

This emergent approach has deliberately attempted to connect with other developments in

critical social and health psychology and with critical developments in community

psychology (e.g. Kagan, Burton, Duckett, Lawthorn, & Siddiquee, 2011). In devising

strategies for social and community change, critical health psychologists are aware of the

need to understand and to respect the local knowledge held by communities. As

Jovchelovitch (2007) has argued, a starting point for change must be ‘a deep commitment to

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the belief that ordinary people have a contribution to make and know what they are talking

about and an acceptance of the incompleteness and limitations of one’s own knowledge’ (p.

156).

Community health psychology also places a focus on enhancing community wellbeing rather

than on managing individual sickness. Thus it can take up issues such as poor housing and

lack of resources which contribute to individual ill-health. Sometimes the links can be

explicit such as challenging particular environmental toxins that contribute to specific health

problems. An example of this is that environmental justice campaign of Sullivan, Petronella,

Brooks, Marillo, Primeau & Ward (2008). In this project Sullivan and his colleagues worked

with residents of polluted neighbourhoods highlighting the links with respiratory illness and

the need for environmental change. Other times the concern is more general and overlaps

with the more general community psychology.

Participatory action research

An important feature of much community health psychology is the active involvement of

community members in the research process. This approach is the basic tenet of

participatory action research in which the group or community are actively involved in all

aspects of the research from developing the research question, through to designing the

research methods, collecting the data and promoting various forms of social action.

Through this approach the participants become co-researchers in the process identifying the

obstacles to social change and their own role in the change process. This approach is

informed by the critical literacy developed by Paulo Freire. He characterised the traditional

approach to education as ‘an act of depositing, in which the students are the depositories

and the teacher is the depositor’ (Freire, 1970, p. 53). In the more critical approach, the

educator engages with the students in an active dialogical manner to encourage them to

consider the broader social and structural restraints on their lives and how they can begin to

challenge these restraints through collective action. He used the term conscientization to

describe this process of developing critical consciousness: ‘Problem-posing education

affirms men and women as beings in the process of becoming – as unfinished, uncompleted

beings in and with a likewise unfinished reality’ (p. 65).

Freire stressed that his work was ‘rooted in concrete situations’ working with poor peasants.

He emphasised the collaborative nature of his work and described the radical as someone

who ‘does not become the prisoner of a “circle of certainty” within which reality is also

imprisoned ... This person does not consider himself or herself the proprietor of history or of

all people, or the liberator of the oppressed; but he or she does commit himself or herself,

within history, to fight at their side’ (p. 21).

Freire’s philosophy highlighted a belief in the potential of ordinary people. In his writings

he stressed the need to actively engage in dialogue with people as part of the process of

personal and social transformation, the development of critical consciousness. It was the

opportunity to engage in active dialogue which is at the heart of change. It is through this

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process that people learn to critique the nature of their reality. As Freire stressed, “To

surmount the situation of oppression, people must first critically recognize its causes, so

that through transforming action they can create a new situation, one which makes possible

the pursuit of a fuller humanity” (p. 29).

Freire’s popular education is designed to promote this process of dialogue and critical

reflection. He notes how oppressed people have internalised feelings of worthlessness and

powerlessness. The challenge of the popular educator is to work with them to discover their

strengths and potentials through the process of reflection and action. At the centre of this

process is the quest for human freedom and authenticity. Freire argues that “[f]reedom is

acquired by conquest, not by gift. It must be pursued constantly and responsibly. Freedom

is not an ideal located outside of man; nor is it an idea which becomes myth. It is rather the

indispensable condition for the conquest for human completion” (p. 29).

These ideas have been the cornerstone of popular education for forty years. Although they

were developed at a time of brutal oppression they still have relevance today where the

challenge is to insert them into a world of consumer capitalism which offers the promise of

human fulfilment through individual lifestyle choice rather than collective struggle. It is not

an approach that is familiar to most health psychologists although there is increasing

discussion on its potential. For example, Brydon-Miller (2004) notes how it has been

enriched by other theoretical frameworks, in particular feminist theory. These new

frameworks have emphasised the need for continual reflexivity (e.g. Finlay & Gough, 2003).

From local action to broader social change

The focus on local social action has some implicit dangers if the researchers do not reflect

upon the broader socio-political context. For the past ten years or more there has been a

move to decentre the role of the state through the privatisation of health and social services

and the downloading of responsibility not only to the individual but increasingly to the

community. Thus communities that are already disadvantaged have the additional burden

of being considered responsible for their condition. This becomes the new contemporary

form of victim blaming. Previously, we argued:

“By locating the responsibility for health problems within marginalized local

communities, such analyses serve as a smokescreen for governments who seek to

reduce welfare spending [etc.]” (Campbell & Murray, 2004).

Health psychologists have an important role to play in challenging this new extended form

of victim blaming. This requires ongoing reflection on our practice as well as a commitment

to broader social change. While community action can enthuse and excite large numbers of

people we need also to consider the broader political context within which it develops and

whose interests are primarily served by its promotion. The recent growth of interest in

community activism by conservative politicians has contributed to sustained reflection

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about its basic assumptions. Internationally this debate has been fanned as versions of

participatory community action have been adopted by world development agencies as a

means of imposing globalisation and the interests of multinational corporations. Thus

rather than working to promote the interests of marginalised community members this

approach can become a means of concealing a bigger transnational agenda (Kindon, Pain &

Kesby, 2007). It can become a means not of challenging established power interests but

rather of pushing responsibility back on the poor and excluded. As Kindon et al have stated:

‘while participatory approaches seek socially and environmentally just processes and

outcomes, they none the less constitute a form of power and can reproduce the very

inequalities they seek to challenge’ (p. 2).

It is for this reason that Cooke and Kothari (2001) described participation as the ‘new

tyranny’. By this they meant that rather than challenging structural inequalities

participatory projects have often ignored the workings of the system and as such

contributed to its maintenance.

Historically, critical psychologists have emphasised the importance of reflexivity. This has

meant different things to different researchers but broadly it is the concern to reflect upon

our practice in the collection and in the interpretation of data collected. In the case of

scholar activists, issues of reflexivity become more important since it is concerned with

multiple issues from the research/action, the interpretation of data, the use of data, the

relationship with the community, etc.

The danger is to become over-involved in local projects to the neglect of awareness of the

larger socio-political context. An important part of this process is the extent of critical

engagement with the broader political agenda. There is an ongoing need for scholar-

activists to connect local action with the broader socio-political and cultural context and

within an ongoing process of critique and reflection (Murray & Poland, 2006). Thus rather

than imposing a fixed agenda the researchers work with members of groups, communities

and broader social movements to excavate and challenge the structures that disempower

them and exclude them from power.

Community health psychologists are aware of the limitations of focusing solely on singular

and localised projects. They often report that while community residents can be enthused

by local activities they are frustrated at the obstacles to broader social change. As Campbell,

Cornish, Gibbs & Scott (2010) recently noted: ‘such projects are frequently successful in

building the ‘voice’ of the poor, but less successful in building ‘receptive social

environments’’ (p. 963). They argued that there is a need to turn our attention to exploring

broader social movements that can create such ‘receptive social environments’. This is a

major challenge for community health psychologists who have as of yet given limited

attention to the processes involved in these larger social movements.

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Campbell et al define ‘voice’ as ‘the capacity of poor people both to develop critical analyses

that link their poverty to wider social inequalities and to articulate forceful demands on the

basis of these critical understandings. ‘Projects develop voice through providing

transformative social spaces for dialogue in which poor people are able to engage in critical

thinking about the social roots of what might previously have been regarded as individual

problems’ (p. 963). This is the typical work of the community activist but the challenge is to

move beyond this local development of critical thinking and action. Campbell et al illustrate

the process of building receptive social environments within which this local social action

can move to a higher level through an analysis of a number of collective health movements.

These movements were able to build this receptive social environment by a) uniting a broad

range of people behind its objectives and b) promoting a moral symbolic agenda for change.

Such a process of building a supportive social environment can occur at the local as well as

at a broader level.

Lott & Bullock (2007) have identified a range of such broader activist strategies. They begin

by stressing the need to reject individuating theories of poverty and wealth as was

emphasised by Ryan forty years ago. To this we can add opposition to the process of

collective victim-blaming whereby we can denigrate whole groups or communities. Instead

we need to consider who benefits from this process of victim-blaming and how they can be

challenged through various forms of social critique and action. Such challenges can vary in

magnitude over time and place but behind them is a common commitment to social justice

(Murray, Nelson, Poland, Maticka-Tyndale & Ferris, 2004).

Critical health psychologists today can learn from the many struggles of disenfranchised

people over the years. By working at different levels and with different social groups and

movements they can contribute more actively to the development of a more equitable and

healthier society. Through connecting critical scholarly and activist traditions they can not

only be involved in deconstructing oppressive discourses but also be engaged in different

forms of collaborative challenge and resistance to symbolic and material oppression.

Researchers and activists in community health promotion (e.g. Jacobs, 2006) have argued

that a central concept in their approach is that of empowerment. This concept has been

defined by Wallerstein (1992) as:

A multilevel construct that involves people assuming control and mastery over their

lives in the context of their social and political environment; they gain a sense of

control and purposefulness to exert political power as they participate in the

democratic life of their community for social change (p. 198).

An important part of this definition is that community health action is seen as collaborative

with the community and critical as regards broader societal institutions and structures. As

Levarack (2004) stressed:

Empowerment has an explicit purpose to bring about social and political changes,

usually through affecting public policies, decision-making authority and resource

allocation (p. 87).

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Community health psychology has the opportunity of developing an understanding of these

changes through active engagement.

Arts and social change

The arts have historically played an important role in both discouraging and facilitating

social action and change. Art can be characterised as either anaesthetic or aesthetic. By

anaesthetic is meant that art can dull the senses and diminish questioning of the social

order. Conversely art as aesthetic can be concerned with increasing awareness. It can draw

attention to issues that are often ignored. It can encourage a reassessment of the everyday.

In his review of the role of arts in health care Camic (2007) argues that “the arts can

challenge people to think differently, engage in different behavioural experiences and

experience different emotions” (p. 288).

Different forms of art can involve people emotionally. As such they can be both a source of

personal satisfaction as well as a catalyst for social action. People can be involved to

varying degrees in the arts from observers through to active participants. Artists have

sought to involve people in their work – the success of an artwork is bound up with its

success in emotionally as well as cognitively engaging the audience.

The arts can play an important role in building such a supportive social environment through

mobilising large numbers of people and articulating a moral agenda. Individual artists have

historically played an important role in drawing attention to injustice and visualising a new

agenda. As Adrienne Rich (2006), the American poet and feminist argued:

Poetry has the capacity to remind us of something we are forbidden to see. A

forgotten future: a still uncreated site whose moral architecture is founded not on

ownership and dispossession, the subjection of women, outcast and tribe, but on the

continuous redefining of freedom – that word now held under house arrest by the

rhetoric of the ‘free’ market. This on-going future, written off over and over, is still

within view.

The power of poetry to become an organiser for change was confirmed recently in the Arab

uprisings where the words of poets were enthusiastically taken up by the masses. Tamim al-

Barghouti, a Palestinian poet, argued that the use of poetry in Tunisia had “widened

people’s imagination, changed their perception, increased their self-confidence and showed

them how fragile their tyrants are”. The state realising the revolutionary power of poetry

deliberately targeted its advocates. In Bahrain a woman was sentenced to a year in prison

for reading a poem which included the lines, “We are the people who will kill humiliation

and assassinate misery. Don’t you hear their cries? Don’t you hear their screams?” (Fenton,

2011).

Central to the process of social change is the leadership provided and the articulation of a

new collective story by and with the community. The role of leadership in all forms of

social action is central. The leader can inspire, support, and challenge community members

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(Morris & Staggenborg, 2004). Stories can be an important means by which the leader can

engage the community and encourage reflection. Storytelling has often been consigned to

the sideline in discussions about social change – they are often considered a diversion from

practical issues. But stories convey the history and trajectory of a community as well as

provide a guide to future action. As Selbin (2010) argued:

‘... often we use them [stories] not just to narrate our lives [...] but to tell, to share

news, information and much more: to guide, to warn, to inspire, to make real and

possible that which may well be unreal and impossible. Stories allow us to imagine

the transformation of our lives and our world.’ (p. 3).

In his review of collective movements of change, Selbin concluded that ‘the crucial factor in

explaining how and why revolution persists is the stories of revolution, rebellion, and

resistance we tell’ (p. 3). Within the community one of the roles of the critical educator is to

work with the community to reflect on and critique their experiences and begin to develop a

change strategy which takes the form of a story of potential – what can be done. Selbin

stressed ‘the importance of the articulation of compelling narratives and stories in any

meaningful effort at change’ (p. 194).

Political movements can be galvanised around vivid stories of potential change. Consider

the case of the civil rights movement in the United States which was epitomised in Martin

Luther King’s ‘I have a dream’ speech which only lasted 14 minutes but continues to

reverberate. Similarly powerful folk songs such as Woody Guthrie’s ‘This land is your land’

can enthuse millions. The lyrics can be drawn upon by politicians. For example, Barak

Obama used the phrase ‘It’s been a long time coming but tonight change has come to

America’ on the day of his election victory, drawing from Sam Cooke’s civil rights anthem ‘A

change is gonna come’. In Britain there is a long tradition of political songs (Lynskey, 2011).

An example is Billy Bragg’s ‘Between the wars’ which invigorated supporters of the miners’

strike with his call: ‘I’ll give my consent to any government/that does not deny a man a living

wage’.

Certain community narratives can also play a reactionary role by excluding people from

involvement in activities such that it becomes the role of the community activist to

challenges such narratives and to develop alternatives. This is not an easy task since

communities have shaped their identities around such narratives and they are often

reinforced through songs and images. The gradual assertion of new narratives can often be

subverted by older tales of reaction. The scholar-activist is aware of this clash of narratives

and how they can inhibit the process of change. It is through a combination of forms of local

action, alternative narratives and trusted leadership that communities can begin to explore

new ways of working and living.

An example is the work we did in promoting awareness of the occupational health hazards

within the deep-sea fishing industry (Murray & Tilley, 2006). Traditional approaches

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focused on promoting safety awareness among individual fish harvesters. Such an approach

mirrored the victim-blaming approach condemned by Ryan 40 years ago. Our approach was

to engage whole communities in this process and to highlight a wider agenda for safety

action. This involved a variety of community arts activities including plays, concerts and

exhibitions. An important part of this project was the songs that we developed with local

residents. In one community we worked with a folk singer who drew upon interviews

conducted with fish harvesters and developed a series of songs about fishing and safety.

When played at local concerts and on the radio, these songs had a powerful echo in fishing

communities and contributed to developing a receptive social environment. However,

despite substantial local and national interest, for various logistical and funding reasons, it

was not possible to further extend this project. This illustrated the tensions often

experienced by scholar activists between the success of local social action and longer-term

social change.

Another example is the CALL-ME project which was established to explore the character of

social isolation among older residents of a disadvantaged urban neighbourhood and to

investigate the potential of collaboratively developing community social activities (Murray &

Crummett, 2010). One such activity was a community arts project. This is defined as the

use of multiple forms of creative arts activities in a community setting. It requires the active

involvement of local people in its development and an awareness of the broader socio-

political context within which the action is located (Webster & Buglass, 1997). At the outset,

the researchers invited a group of older residents to reflect upon their neighbourhood and

to consider a plan of action to promote social interaction. When the idea of a community

arts project was introduced some of the local residents were ambivalent but agreed to

participate not least because it was something to do.

Over a period of two years a group of older residents met on a weekly basis to experiment

with a range of art forms including painting, pottery and glass engraving. They met for two

hours each week and were led by a local community arts worker. During this period they

completed a number of arts projects. At the completion of each project the participants

organised a community exhibition of their work. They invited not only local residents but

also city officials and local politicians. In this way, the project moved from an opportunity

for social interaction to one that challenged dominant negative social representations of the

community held by outsiders and began to become a form of social action.

It was through a process of dialogue and local action that members of the community began

to question their circumstances, to articulate their needs and begin to develop the

community arts projects. The results of these projects were a source of great community

pride which promoted substantial wider discussion. However, as previously emphasised, the

success of such local action needs to be considered with reference to the support or

otherwise of the immediate social environment, its history and culture, the character of the

leadership offered, and the broader political climate within which the action is located.

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A recent evidence review by the UK Mental Health Foundation (2011) on the impact of

participatory arts on the health and wellbeing of older people concluded that while the

research to date indicates that such activities can be very beneficial to the participants there

is a need for further research. One challenge is the relative limited research expertise of

community artists. Health psychologists can play a very important role in assisting in the

development and evaluation of such interventions.

While arts can ask questions it is the linking with political action that it can lead to social

change. Within the community arts movement there has been continuing debate about the

limitations of local arts activities. As Duncombe (2007) argues:

Cultural resistance, unless translated into political action can become ‘imaginary’

solutions to real world problems and create ‘magical’ communities in the place of

real ones’ (p. 498).

However, there is also the danger of over-pessimism leading to lack of any action. In the

darkest night there is always room for hope and that is something we can learn from

history. As Duncombe concluded:

For all the problems with cultural resistance, there is still potential. For in cultural

resistance lies the possibility of imagining and creating something different. People

who have little access to political power or material wealth can express through

culture their criticisms of their current situation and conjure up a vision of something

different’ (p. 498).

The grass is singing

Much of traditional health psychology is imbued with what Martin-Baro (1984) has

described as ‘scientistic mimicry’ with the aim to develop universal laws which can describe

the relationship between variables. Conversely community health psychology is concerned

with not how things are but what they can become. Its focus is not on describing but rather

on transforming the social world and enhancing community health and wellbeing. The form

of its research practice is collaborative and change oriented. Recently, the Australian

linguistic scholar Anna Wierzbicka (2011) reflected on character of psychology and what it

can learn from the humanities. She defined the humanities as the study of human

experience and more specifically ‘what can happen to people and what people can do;

possible ways of thinking, ways of feeling, and ways of speaking; possible motives and

possible values’ (p. 38).

This definition places an emphasis on potential rather than fixity, on diversity rather than

uniformity. In doing so it opens up multiple ways of seeing the world but also ways of

creating a new and hopefully better world. As Wierzbicka argues:

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‘The humanities’ seeks also to provide opportunities for people to think about how

someone can live, and whether it is good or not good for people to do things of

some kinds. This is not something open to empirical verification’ (p. 40).

This quest for personal and social transformation lies at the root of community health

psychology.

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