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Jefferis.S, Summer 2023, A CAT View of Social Innovation and Capabilities: Hilary Cottam’s “Radical Help” , Reformulation 56, p. 14-16
“When people feel supported by strong human relationships, change happens. And when we design new systems that make this sort of collaboration and connection feel simple and easy, people want to join in” (Cottam, 2018, p15)
Introduction
This article is an introduction to the ideas of Hilary Cottam. Her book “Radical Help: How we can remake the relationships between us and revolutionise the welfare state” (2018) is a reckoning with the difficulties of the welfare state as currently constituted, and an exploration of alternatives based on relationships and connection as the key resources. Throughout, her relational approach has strong resonances with CAT. What follows is a description of the ideas and an attempt to translate them into CAT concepts with the help of two maps. Cottam’s work certainly challenges the traditional structures of services that many of us work in, including the NHS, and may have something new to offer CAT practice.
Cottam describes herself as a social activist. Her work fits with the concept of “social innovation”, defined as “new solutions … that simultaneously meet a social need (more effectively than existing solutions) and lead to new or improved capabilities and relationships and better use of assets and resources” (Young Foundation, 2012). In essence, her work is about stepping back from the traditional ways that social and health needs have been met. These have too often involved “doing to” people, at the neglect of people’s own relationships, networks and autonomy. Instead we should experiment with different systems to meet those needs. Cottam’s organisation Participle (participle.net) has run five experiments addressing the needs of the ageing population; work; long term health conditions; the needs of young people; and the problems facing families with complex needs. A description of those experiments forms the core of the book. They follow a design process that starts with listening to people’s actual experience of life in their particular context, and aims to build networks and relationships through support, that over time enables people to develop their capabilities rather than rely on intervention from outside.
Some of these ideas overlap with Community Psychology, and Cottam acknowledges she is building on the work of other social innovators. While socially progressive, Cottam’s work includes a critique of the attempts to solve social problems by the political left, or rather the way the left has got locked into a limited way of thinking about the welfare state.
There is of course already work taking place (including CAT informed work) which does follow a more collaborative, doing-with approach, in the NHS and other welfare state institutions. Cottam argues that the functional logic of these systems makes such work difficult, even where it exists, and so we need to rethink the structure of the entire welfare system for meaningful change to take place. To illustrate, I am going to write from the maps that accompany this article. I have framed the maps generically so they could apply to health, social care, employment services or other welfare settings. The words and maps are mine, describing Cottam’s ideas. Numbers in square brackets are there to help readers navigate key points on the map.
A relational understanding of the welfare state – map 1
Cottam begins by revisiting the 1942 Beveridge Report which led to the foundation of the welfare state. The transformational scale of the change it created is easy to forget: the “Dickensian Britain where most people died in their sixties … and heating was a luxury… was swept away”. She points out that Beveridge originally envisaged a strong role for the voluntary sector and was ambivalent about the state taking over so comprehensively.
There is recognition from all sides of the political spectrum that many of the institutions of health, social care, employment support etc. are not working as they should. Cottam argues there are fundamentally different challenges now to those the welfare state was set up to address, including: the difference-in-kind of modern welfare challenges such as long-term health conditions and the globalised workplace; the crisis of direct care provision; and ongoing poverty and inequality. In healthcare, for instance, an industrialised, medicalised “conveyor belt” method was effective for major post-war health challenges such as pneumonia and polio. This method is much less effective for addressing conditions like obesity and diabetes where a cure is not in sight and effective management relies on a more complex interplay of psychological and social factors, as well as the active involvement of the patient. The same is true for psychological problems where an illness model may not just be inaccurate but cause iatrogenic harm. Poverty is argued to take a crucially different form from Beveridge’s age because work often pays so much less than is needed to alleviate poverty, that the state is stepping in to top up wages. Furthermore rising inequality generates immense psychological competition, stress and shame in relation to income and status, as well as damaging our relationships (as explored by another CAT-friendly social policy book, Wilkinson & Pickett’s “The Inner Level” (2018)).
So, on the map, the starting point is the (possibly overwhelming) complexity of needs, suffering and risk present in our collective lives [1]. Our inherited welfare system responds to this with an “elaborate and expensive system of managing needs and their associated risks”. The model is one of people and their needs as industrial units, passed between institutions. Since the 1980s, the “new public management” approach has been dominant: the introduction of commercial practices with the expectation that this will increase the efficiency and effectiveness of state run institutions. The market ideology of commissioning and competition remains a firmly embedded reality for most public services. Accordingly, debates around reform of the NHS and other welfare systems all tend to be conducted through the lens of re-organisation of the existing institutions. The systemic logic is about managing scarcity, and the bulk of the resource is spent on gatekeeping (managing the queue, cross referrals, recording and admin).
Relationally speaking, this can manifest as a reciprocal role of bureaucratic and ritualised to dehumanised and unseen [2]. Professional staff may feel constrained, stressed and deskilled, leading to a dilemma of either cut off or leave (burn out) [3]. Impersonal provision of care, and the labyrinth of bureaucracy people may face, creates relational resentment from people navigating the system. This tends to add to the original problems or leads people to give up [4].
The gatekeeping which follows from such a system will lead to some people being excluded. This may exacerbate existing feelings of rejection and deprivation (withholding/depriving to excluded and deprived [5]), which tends to add to the levels of need in a feedback loop. Alternatively, for those deemed eligible to receive a service, despite good intentions very often the service follows a relational style of caregiving / doing to to dependent recipient [6]. The industrialised model favours treatment or care which can be prescribed in this way. This relational pattern has been further fostered by the creeping expansion of a “service industry” model – the notion that for every need there should be a service to fix it, and we want it “free, perfect and now” (a perfectly caring and rescuing reciprocal role).
The left’s approach to welfare engages empathically with the very profound needs of all kinds in the population, but typically it then attempts to meet those needs by serving them rather than attempting to grow the capabilities that will help those needs resolve rather than recur. Hence this tends to contribute to the procedure, leading to further need and demand. Expectations from the public also rise to a level which can be impossible to meet.
There have of course been many attempts to address these systemic difficulties. These can be summarised in a dilemma. From the political right [7], the accusation is that the welfare state is too big and bloated. Working from a naïve folk psychology, their solution is that “people should help themselves” (enabling cuts to welfare), leading to the withholding-to-excluded reciprocal role. It is as if that will magically lead to the discovery of the “will power” to solve their own problems. This is an enactment of the punishing/blaming to punished/blamed [8] reciprocal role, which itself exacerbates problems further. On the political left, the preferred solution is simply to fund the institutions properly, as if that in itself will solve the systemic problems [9]. But too often the left is so concerned to mount a defence of the embattled welfare state that it can’t accept there is a problem with the system, and the additional resources feed further doing to. In any case, any new resources are instantly subject to constraints and expectations on outcomes that normally lead to further gatekeeping [10]. Both sides of this dilemma focus on the money and rearranging the institutions. Furthermore, efforts at reform mostly get snagged on their top-down nature: as Cottam puts it, “pulling the industrial levers of power [to change the NHS] seems to make very little difference”.
Exits via social innovation – Map 2
The central difficulty is nicely captured in Cottam’s aphorism (p42) that “our welfare state might still catch us when we fall, but it cannot help us take flight… we hoped for safety nets that would [act as a] trampoline but instead we find we are woven into a tight trap”. So how could things be different?
The five experiments in the book all follow patterns that can be understood in CAT terms as exits from the difficulties outlined in Map 1. The scheme with older people called “Circle” links all kinds of people in later life together into a co-operative self-help network which addresses loneliness, fosters mutual help and shared interests, and provides a collective resource when practical help is needed. The scheme for long term health conditions, “Wellogram”, has at its centre a “relational worker” whose role is a non-expert blend of psychotherapist and collaborative problem-solver– crucially working alongside rather than for them, able to “manage the anxiety of not intervening” to allow the person to take their own steps. The scheme with teenagers, “Loops”, invites young people to choose from a directory of free “experiences” in different local workplaces, cultural spaces, and so on, leading both to the forming of new relationships and reflection on their experiences, generating connections, inspirations and new possibilities.
The outlines here only hint at the elegance of the actual schemes, which are described in detail in the book, but the general design principles may be potential exits for any of us working within these systems. I will describe these by walking around map 2, which starts in the same place as map 1 - the same knotty challenges of suffering, risk and enormous needs [1]. Cottam’s work does not downplay the real hardship in people’s lives, but starts from the point of pulling back and asking what kind of life people want. The reasoning is that, if any scheme to help connects first with people’s dreams and wishes (however fanciful), there is a starting point from which to engage and to build. There is a reciprocal role of listening, learning and reflecting to seen & heard, present and respected [2]. All the experiments begin with a process of just being present with people and hearing what things are like. There is a holding back from providing answers; a disposition of sharing power; and attention to root causes rather than the surface problems. Crucially there is an invitation in to these experiments rather than a compulsion to attend – a fundamental relational difference which in itself creates a radically different dynamic to many existing social interventions.
From this listening stance, a plan to address the needs starts to be formed. Two relational patterns are evident in the scheme designs. The first is guided by a principle not of “how can I fix you?” but “how can I support you to make change?” [3]. The reciprocal role is enabling, encouraging, doing with to actively growing, enabled and participating – an exit from the doing to/dependent role on Map 1. There are examples scattered through the book of people who’ve previously responded resentfully, angrily or avoidantly to traditional services’ doing to approach, starting to flourish when taken seriously as genuine collaborators. Interestingly this process has a Vygotskian flavour, being highly tool mediated with the project teams using simple tools to facilitate the work – e.g. network mapping exercises, problem solving tools etc. The aim is always growing capabilities [4].
Cottam borrows the concept of capabilities from the work of Nobel-winning development economist Amartya Sen and philosopher Martha Nussbaum, who may be familiar to some CAT readers from her work on shame (Nussbaum, 2004). In Sen’s terms, “capabilities are the real freedoms that people have to achieve their potential doings and beings”. This is partly about developing skills and abilities but it has a strong flavour of potential. Cottam argues that welfare systems that do this are both more financially sustainable and humanly respectful of their users as real people, active agents rather than passive recipients. Cottam outlines four key capabilities necessary for human flourishing, which are held in the various experiments: work & learning; health & vitality; community; and relationships. Over time, people grow more able to help themselves but also others, allowing a freeing and destigmatising blurring of roles between helper and helped.
The other relational pattern evident in the experiments is connecting, resourcing, new possibilities to connected, resourced and open [5]. Most of the experiments explicitly include the building of relationships and social connections as a key resource [6]. Part of the problem with existing welfare systems is that they do not tend to go with the grain of helpful human relationships: they may separate people from naturally occurring systems of support, or gate-keep in such a way that existing resources and relationships then disqualify people from help. The value of relationships is central to CAT, but seeing this at the centre of a model of social policy was new for me. Also new was the insight that, once you start looking at relationships as the key resource rather than funding, it upends the traditional model of resource management: here, the more people that participate, the better and stronger the service or the system. This is the opposite logic to that of managing scarcity which sees the eligibility criteria for services set so tightly they are only accessible to a vanishingly small minority.
The final step on the exit map is a continuous process of reflection, listening and planning again [7]. A formal reflective process is a key part of most of the experiments, and Cottam references analytic psychotherapy texts on reflective practice in support of this. Crucially, as mapped here, there is no feedback loop adding to the entry point of need and suffering, in contrast to map 1.
Reflections for CAT
The parallels with CAT thinking will be clear. Cottam’s model involves an iterative process of listening, engaging and supporting that, in its shift in the balance of power, corresponds to the kind of relational style Ryle intended for individual therapy. Regarding individual work, the value of stepping back and starting with people’s dream of a good life is worth remembering. We might be wary of colluding with fantasies, but dreaming is human and I was reminded of a CAT supervisor who liked to ask, at assessment for CAT, “What makes the heart sing?”. It can be easier for therapists to be compelled by narratives of distress, neglect and difficulty, rather than the dream of a better life.
The notion of capabilities may also be useful in considering exits in CAT therapy. In complement to a strengths approach, which is more about already established skills, the notion of capabilities implies potential: skills that are not quite there yet, or waiting in the shadows, or just need catalysing in some way – fertile ground for a time limited therapy.
Some of the tools referenced in the experiments may be worth investigating for individual CAT therapy, for example network mapping and capability development tools. We might also consider whether exits aimed more explicitly at establishing new relationships and growing personal networks should be articulated more often.
In CAT consultancy, the model presented here perhaps articulates new possibilities for ways of organising our services, and recognising the constraints of our current systems. When doing CAT organisational consultation with mental health teams, I have been struck by how often the starting point on the map is just the same as map 1: an “overwhelming scale of need” in the population served, and the way this leads directly to unhelpful systemic procedures around rescuing, guilt and bureaucracy to keep feelings of helplessness at bay. This model may allow us to name clearly the fact that the scale of need is often more than our current systems can respond to, enabling a greater degree of compassion within the system. It also prompts us to question the ways our teams still do to rather than do with, in explicit and implicit ways. Many of us will be aware of services that look more like map 2, perhaps in the third sector. Perhaps we can also do more within our traditionally organised NHS structures. This might be meaningful service user involvement (which, among other things, has a role in growing connection and capabilities), or returning to models like Sue Holland’s (1991) Social Action Psychotherapy.
One issue not tackled in the book is where the desirable balance might lie between the traditional and new ways of organising care. At times it can feel Cottam downplays the huge achievements still delivered by the NHS, often using an industrial model which at times remains useful (e.g., writing in September 2021, the Covid vaccination roll out). Overall however, Cottam’s work resonates with CAT thinking and can enrich our relational understanding of what might be possible in re-imagining how we meet the ever more complex needs of our communities over the coming decades.
Steve Jefferis is a Consultant Clinical Psychologist, Clinical Lead for the CNTW CAT Service, and Course Director for the Newcastle CAT Practitioner Training. steve.jefferis@cntw.nhs.uk
References
Cottam, H. (2018). Radical Help: How we can remake the relationships between us and revolutionise the welfare state. London: Virago.
Holland, S. (1991). From Private Symptoms to Public Action. Feminism & Psychology, 1(1), 58–62.
Nussbaum, M. C. (2004). Hiding from Humanity: Disgust, Shame, and the Law. Princeton University Press.
Robeyns, I. and Byskov, M. F. (2020). "The Capability Approach" in The Stanford Encyclopedia of Philosophy (Winter 2020 Edition), Edward N. Zalta (ed.). Viewed 20 Feb 2021, <https://plato.stanford.edu/archives/win2020/entries/capability-approach/>
Wilkinson, R. & Pickett, K. (2018). The Inner Level: How More Equal Societies Reduce Stress, Restore Sanity and Improve Everyone's Well-Being. London: Penguin.
The Young Foundation (2012). Social Innovation Overview: A deliverable of the project: “The theoretical, empirical and policy foundations for building social innovation in Europe” (TEPSIE), European Commission – 7th Framework Programme, Brussels: European Commission, DG Research