Communities of Practice and Women’s Mental Health
Defining “community” in community mental health
The mental health and psychosocial needs of women in low-income settings of the Global South have gained increased attention with the rise of the Movement for Global Mental Health (MGMH). As part of MGMH’s efforts to scale up services in limited resource settings, communities are viewed as mediators of MH, with community engagement being recognized as a key locus of action.(1) While MGMH frequently invokes the need for greater community involvement, understandings of “community” vary among stakeholders. The multifarious ways in which the term is used, particularly in relation to the promotion of women’s MH, makes action at this level a complex process that requires further exploration.
Although it is widely established that community promotes and supports emotional wellbeing among women in marginalized and extreme settings,(2) the notion of community itself is slippery. It might refer to a bounded geographical location; or to the culture, practices or ideals shared by a group of people; even to religious or political ideologies or positions.(3) The bulk of existing work on community MH with regard to women remains situated within a biomedical discourse, in which “community” refers to a place, or a physical space, where the delivery of mental health support services can be coordinated.(4) From a service delivery perspective, such a view of communities is pragmatic, given that health services are distributed district-wise, and mental health practitioners (MHPs) allocated to regions based on population levels within defined geographic areas.
Exclusively place-based understandings of community may, however, obscure relational and social aspects. Evidence suggests that psychosocial aspects of “community” life, including social support networks, degrees of social cohesion and collective self-efficacy, have significant bearing on women’s MH. It has been found,(5) for instance, that high levels of perceived trust within communities is positively associated with management of HIV-related distress among women. Scholars have also found,(6) on the other hand, that social connections may actually add to distress among women in resource-poor settings, through the obligation to provide support to others in the community. Some social and community psychologists therefore argue that research studies and intervention programs need to complicate understandings of the term community.(7) Few studies on women’s MH in the Indian context however, have focused on examining community from a psychosocial perspective. In the present article, I examine the role of communities of practice in supporting women’s mental health in low-income settings.
Women’s understandings of “community” in low-income settings
This analysis is based on a study of a community education project set up by the NGO Muktangan to improve the quality of educational provision in mainstream government schools in Mumbai. The case study was built around interviews and focus group discussions with 20 teachers and other frontline staff at Muktangan – women recruited from the same marginalized communities as their students. The author conducted telephonic interviews with participants, given the COVID-19 crisis. Due to the implementation of measures such as physical distancing, this crisis presents an unusual opportunity to understand the psychosocial relevance of community in supporting women’s MH.(8) The interviews sought to understand the meanings participants attached to “community”, both in the context of the pandemic and beyond, and the role of these communities in supporting their mental health.
The women participants tended to emphasize social and relational aspects of community in discussing how they managed their mental health. They spoke of community in the sense of communities of practice – referring to groups in which ties develop between members through regular conversations about matters of common concern.(9) In the context of the present study, such communities of practice had evolved through the professional development activities and group discussions participants have as teachers: they spoke of how these communities, cultivated over the years while working at Muktangan, had given them access to alternative forms of association, and benefited their mental health in three significant ways during the pandemic.
“Evidence suggests that psychosocial aspects of “community” life, including social support networks, degrees of social cohesion and collective self-efficacy, have significant bearing on women’s MH”
mental health outcomes during the coronavirus crisis
Several participants said that while physically distanced from each other and from their organization, they remained connected to their feminist values and identities, from which they drew a sense of power and agency within their households. Many spoke of recognizing their own contributions to their families’ wellbeing, and being able to assert their own needs and preferences during the present challenging circumstances.
Secondly, the women felt they had gained from having access to social relationships predicated on unity and solidarity, as distinct from the given relationships of family and kinship. There was reflection on how, prior to working at Muktangan, they had been embedded solely within their “communities of birth”, with their patriarchically organized families placing them in subordinate positions to men. Working with the NGO had enabled them to cultivate communities of their own choosing, building networks with other women in similar situations. The unconditional support they gained from these relationships allowed them to confront unequal relations of power in their own lives and to overcome feelings of social isolation and constraints, as well as negotiate gendered oppression.
Finally, through these communities of practice, participants reported having an enhanced capacity for reflection and problem-solving. Additionally, they felt empowered during the time of crisis by being able to share their worries and concerns, and collectively find solutions.
Communities of practice as a psychosocial resource for women
The Muktangan case study demonstrates how community operates powerfully at a psychosocial level in women’s lives. For the women in this specific setting, their communities of practice had supported more empowering selfrepresentations and social identities, wider social networks and solidarities with other women, and an improved capacity for collective problemsolving.
These communities had played an important role in helping them cope with the social, economic and health-related stressors presented by the coronavirus crisis. Social and community psychologists suggest that communities of practice constitute “social capital” for women in marginalized contexts, who may lack access to other forms of economic and political capital.(10)
The present study has broad implications for communitybased MH work for women in socioeconomically marginalized settings. As noted earlier, definitions of “community” in such initiatives tend to de-emphasize social and relational aspects, using the sole lens of place to view communities as little more than geographical backdrops for interventions. Programs of research and intervention must adopt more expansive and psychosociallyoriented understandings of the ways in which community contexts shape women’s opportunities for MH and, crucially, of the agency and resilience of women in marginalized settings. This would mean viewing communities as experts in their own right, as agents in the promotion of their own MH, and as crucial partners in decision-making – for instance, about biomedical treatment.
Broadening our concepts of community is of particular importance in the current pandemic context. Given the likelihood that measures such as physical distancing will continue into the future, studying and leveraging diverse forms and experiences of community, such as communities of practice, becomes essential for optimizing women’s mental wellbeing, which may be better served by policies and interventions aimed at strengthening community social networks rather than through the increased availability of psychological therapies or drug treatments alone. ¤
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References
[1] Campbell C., & Burgess R. The role of communities in advancing the goals of the Movement for Global Mental Health. Transcult Psychiatry. 2012;49(3-4):379-395.
[2] Burgess, R., & Campbell, C. (2016). Creating social policy to support women's agency in coercive settings: a case study from Uganda. Global public health, 11(1-2), 48-64.
[3] Howarth, C., Cornish, F., & Gillespie, A. (2015). Making community: Diversity, movement and interdependence. In G. Sammut, E. Andreouli, G. Gaskell, & J. Valsiner (Eds.), The Cambridge Handbook of Social Representations (Cambridge Handbooks in Psychology, pp. 179-190). Cambridge: Cambridge University Press. doi:10.1017/CBO9781107323650.015
[4] Jain, S., & Jadhav, S. (2009). Pills that swallow policy: Clinical ethnography of a community mental health program in Northern India. Transcultural Psychiatry, 46(1), 60-85.
[5] Gregson, S., Mushati, P., Grusin, H., Nhamo, M., Schumacher, C., Skovdal, M., & Campbell, C. (2011). Social capital and women's reduced vulnerability to HIV infection in rural Zimbabwe. Population and Development Review, 37(2), 333-359.
[6] Casale, M., Wild, L., Cluver, L., & Kuo, C. (2014). The relationship between social support and anxiety among caregivers of children in HIV-endemic South Africa. Psychology, health & medicine, 19(4), 490–503. https:// doi.org/10.1080/13548506.2013.832780
[7] Campbell, C., & Cornish, F. (2014). Reimagining community health psychology: Maps, journeys and new terrains. Journal of Health Psychology, 19(1), 3-15.
[8] Wenham, C., Smith, J., & Morgan, R. (2020). COVID-19: the gendered impacts of the outbreak. The Lancet, 395(10227), 846-848.
[9] Kabeer, N. (2011). Between affiliation and autonomy: navigating pathways of women's empowerment and gender justice in rural Bangladesh. Development and Change, 42(2), 499-528.
[10] Guerlain, M. A., & Campbell, C. (2016). From sanctuaries to prefigurative social change: Creating health-enabling spaces in East London community gardens. Journal of Social and Political Psychology, 4(1), 220-237.