Psychotherapy and social action model

1. Introduction

Version followed: Sue Holland's own account of her West London estate project in Self & Society ("Motherhood, Melancholia and Mutual Groups", vol. 13 no. 6, pp. 311–313; year not printed in the copy opened, about 1985 [uncertain]), plus the four-stage model from Holland (1992), "From social abuse to social action", as summarised in secondary sources. The 1992 chapter and Holland (1988) are [uncertain]. Where the three-stage version (Chaplin 2005) and the four-stage version (Holland 1992 via Wikipedia) differ, this guide uses the four-stage version and treats "status-quo patient" as the entry state.

What it is. This is not a manualised therapy. It is a community mental-health model and project. Sue Holland, an NHS clinical psychologist with a background in community action, set it up in 1980 on the White City council estate in West London. She worked with very depressed women and their families. The project was later known as the Bridge Project and as Women's Action for Mental Health (WAMH) [source: Holland, Self & Society; Chaplin 2005; Wikipedia]. There is no treatment manual, licence, certification or fidelity measure. Anyone using it is adapting a published framework [source: none found in any source opened; uncertain].

How change happens. Holland held that women's depression is rooted in personal loss and also kept going by gender, class and race. She argued that psychotherapy on its own individualises distress and can turn reactionary. Her model therefore moves people along a path, at their own pace:

1. From passive patient to person, through individual psychotherapy that lifts the worst depression and frees energy.
2. From person to collective recognition, through groups where women see that their suffering is shared and has social causes. She drew on Freire's "conscientisation" for this step.
3. Into collective social action, which women organise themselves to change the conditions that keep them unwell.

Prevention, in her terms, must address both the social structures women have internalised (object relations) and the external structures of class, gender and race [source: Holland, Self & Society; Chaplin 2005 quoting Holland 1988, p. 126].

2. Framework

The four stages below follow Holland (1992) as summarised by Wikipedia. Holland mapped them onto Burrell and Morgan's (1979) four sociological paradigms, the "square". Its outer rows contrast changing individuals to fit social convention with changing social structures [source: Wikipedia; Holland 1992, uncertain].

[source: Holland, Self & Society; Wikipedia; Chaplin 2005]

Progression rules.

• Not every client goes through every stage. Many are content with relief from their symptoms and getting on with their personal lives, and that is a legitimate outcome. Progression follows the client's own inclination [source: Wikipedia summarising Holland 1992].
• Individual work comes first for severely depressed women, because severe depression prevents attending groups or taking action [source: Holland, Self & Society].
• Holland (1992) reported that the three-year trial met its goals: focused private psychotherapy, mental-health promotion and continuity in the community [source: Wikipedia].
• By 2005 the project's work was mostly one-to-one counselling, plus advocacy and accompanying women to hospitals and courts. Chaplin judged that the social-action aim had not been sustained, though other aims had [source: Chaplin 2005].
• Session numbers, group size, how long each group ran and formal criteria for moving between stages were not found in any source opened [uncertain]. Practical defaults are in section 4 and are marked [synthesis].

3. Guiding principles

• Distress is social and political as well as personal. In practice, ask about housing, money, immigration, racism and childcare in every assessment, alongside history and symptoms [source: Holland, Self & Society].
• Symptoms are often shared by people oppressed in the same way. In practice, look for patterns across the women on your caseload in the same area, since these suggest which groups to offer [source: Wikipedia].
• Individual psychotherapy is necessary but not enough. Holland warns that therapy alone can individualise people and be reductive or reactionary. In practice, plan from the first sessions for possible group and community steps, rather than ending at symptom relief by default [source: Holland, Self & Society].
• Lift severe depression first. In practice, do not push a very depressed woman into a group or into activism. Individual work frees the energy that later stages need [source: Holland, Self & Society].
• Depression is about loss. Holland's psychodynamic view links depression to early separations, a deep sense of being bad because one was left, and hostility turned against the self (and implicitly towards others). In practice, the individual work explores losses and separations and the anger turned inwards [source: Holland, Self & Society].
• Offer a meaning-based alternative to purely medical management. Holland contrasted her approach with the medico-psychiatric view, which centres on chemistry and genetics, and worked to wean women off "pharmacological solutions". In practice, open up the meaning of symptoms. Any change to medication goes through the prescriber; the therapist never advises stopping [source: Holland, Self & Society; the prescriber point is synthesis].
• Conscientisation (Freire). Groups link personal suffering to shared social and historical conditions, which also reveals shared strength. In practice, groups move between "what happened to me" and "what has happened to women like us" [source: Holland, Self & Society].
• Reject "self-realisation" approaches that assume people are free. Holland criticised the Growth movement's self-realisation approach because it assumes people are essentially free. In practice, do not frame recovery as personal choice or positive thinking while ignoring real constraints [source: Holland, Self & Society].
• Address both inner and outer structures. Prevention has to target internalised social structures (object relations) and external class, gender and race structures. In practice, keep both the psychodynamic and the structural formulation in view [source: Chaplin 2005 quoting Holland 1988].
• Take culture and race seriously. Holland ran separate groups for Afro-Caribbean women and for women in relationships with men from other cultures. Those groups examined colonialism, immigration rules and Home Office decisions. In practice, offer identity-specific spaces where shared history matters [source: Holland, Self & Society].
• Question received ideals. Holland's groups questioned romantic love as a cultural ideal and what being "loved" actually means. In practice, treat taken-for-granted norms about marriage and motherhood as material to explore together [source: Holland, Self & Society].
• The client sets the pace and the endpoint. In practice, offer the next stage and accept no [source: Wikipedia summarising Holland 1992].
• Women organise themselves. The aim is a structure the women run (WAMH, with its own centre and funding), not a service the professional runs. In practice, hand over leadership and become a resource [source: Holland, Self & Society].

4. Intervention inventory

Holland's published account names the following components: individual psychotherapy, interpretation, help reducing dependence on psychotropic medication, a weekly study group (talk then discussion), identity-based and themed groups, confidential personal-therapy groups, and support for women's self-organisation. Advocacy and accompanying women are documented for the later project [source: Holland, Self & Society; Chaplin 2005].

The sources give no scripted procedures. Where this guide gives step-by-step detail beyond what the sources describe, the detail is marked [synthesis]. All example language is illustrative.

4.1 Entry: meeting the "status-quo patient" and assessing on two levels

• Purpose and when to use. At first contact with a woman whom GP or psychiatric care has framed only as a depressed patient on medication. The model locates her at stage 1 and opens the way to stage 2 [source: Wikipedia summarising Holland 1992]. Holland's account does not say how women reached her [uncertain]. The Tower Hamlets analogue takes referrals from the NHS, GPs, community organisations, self-referral and word of mouth [source: ELFT case study].
• Steps [synthesis built on Holland's principles]:
  1. Take a standard history, including symptoms, risk and current medication with the prescriber's name.
  2. Map the social conditions as fully as the clinical history: housing on the estate, money, childcare, partner and family, immigration status, experience of racism, isolation.
  3. Map losses and separations across her life, including early separations from parents.
  4. Ask how she understands her depression, for example as illness, chemistry, punishment or circumstance.
  5. Explain the offer: individual sessions to understand what the depression is about, with later groups available if and when she wants them.
  6. Agree a review point.
• Example language (illustrative). "You've been given a diagnosis and tablets. I'd like to understand what the depression is about in your life, both what's happened to you and what you're up against now on the estate."
• Watch for.
  • Risk: follow standard suicide risk assessment and safety planning.
  • Domestic abuse and safeguarding of children.
  • Whether she can engage at all, or whether she needs practical help first [synthesis].

4.2 Individual psychodynamic psychotherapy focused on loss

• Purpose and when to use. Stage 2. The goal is to lift the most profound depression and free energy for later stages. It is needed especially for severely depressed women, who cannot yet use groups [source: Holland, Self & Society].
• Theory used. Depression is "ultimately about loss", often an early separation that has gone wrong. That leaves a deep feeling of being bad for having been left, and a melancholic hostility towards the self and implicitly towards others. Holland works from an object-relations frame [source: Holland, Self & Society; Chaplin 2005 quoting Holland 1988]. Frequency, length and number of sessions were not found [uncertain].
• Steps [synthesis; the sources name the focus, not the procedure]:
  1. Set a regular frame: the same time and place, and a stated number of sessions with a review.
  2. Follow her account to the losses: deaths, separations, migration, children taken into care, relationships ended.
  3. Notice self-blame and the sense of being bad, and explore where it comes from.
  4. Make careful interpretations linking current self-attack to anger at those who left or failed her. This anger cannot be voiced, so it is turned inwards.
  5. Link the inner pattern to present conditions, as in 4.4.
  6. Review whether the depression has eased enough for her to consider a group.
• Example language (illustrative).
  • "When your mother left, a child can only make sense of it by thinking she must have been bad."
  • "I wonder whether some of the anger you turn on yourself was meant for the people who left."
• Watch for.
  • Signs it is working: brighter mood, more energy, less self-blame, anger expressed rather than turned inwards, curiosity about other women [synthesis].
  • Interpretations experienced as blame. Holland warns that therapy can be reductive, so pair any interpretation with acknowledging real external pressures [synthesis].

4.3 Working on dependence on tranquillisers and antidepressants

• Purpose and when to use. Holland described much of her individual work as trying to wean people off "pharmacological solutions" before moving them into groups. She was contrasting her approach with the chemical and genetic view of depression [source: Holland, Self & Society]. Her account gives no procedure [uncertain].
• Steps [synthesis; current safe practice; no dosing]:
  1. Explore what the medication means to her, for example relief, numbing, or proof that she is "ill".
  2. If she wants to reduce or stop, refer the decision and any tapering plan to her prescriber. Benzodiazepines and antidepressants can cause withdrawal effects and must never be stopped abruptly on a therapist's advice.
  3. Support her through any agreed taper by attending to the feelings that emerge.
  4. Respect a choice to stay on medication.
• Example language (illustrative). "If you want to cut down, that's a conversation for you and your GP, and I'll help you think through what comes up as you do."
• Watch for.
  • Withdrawal symptoms, a return of severe depression, and rising risk.
  • Any sense that she must give up medication to be accepted for therapy [synthesis].

4.4 Linking inner distress to outer conditions (conscientising interpretation)

• Purpose and when to use. This bridges stages 2 and 3. It moves from a private symptom to a recognition that the symptom is shared and has social causes, so that therapy does not individualise. Holland's groups explicitly link personal loss to wider structures such as colonialism, immigration and racism [source: Holland, Self & Society; Wikipedia].
• Steps [synthesis]:
  1. Once a personal theme is clear, ask what part circumstances play: poverty, housing, isolation with children, immigration rules.
  2. Ask whether other women she knows face the same.
  3. Reflect back both levels without dropping the personal one.
  4. Name that some women on the estate meet in a group to think about these things together.
• Example language (illustrative). "Part of this is your history with your mother. Part of it is being alone with three children on the tenth floor with no money. Do you think other women here feel something like this?"
• Watch for.
  • Relief at being less to blame: a sign it is working.
  • Your political frame being imposed on her. If she rejects the social reading, return to her own meaning [synthesis].

4.5 Weekly study group (basic education group)

• Purpose and when to use. Stage 3, the next step after therapy. Holland describes it as a basic education group that meets weekly. Women join when they feel ready. It gave women, who rarely had time or stimulation beyond survival, housework and childcare, a space to think about wider topics. It ran for about four years [source: Holland, Self & Society].
• Format as published. Holland gives a talk and a discussion follows. Topics included mental health, the Welfare State, the family and social structure. Out of these discussions some women went on to set up their own structures [source: Holland, Self & Society].
• Steps [published elements plus synthesis]:
  1. Fix a weekly time with childcare arranged, and keep the group open-entry.
  2. Agree topics with the women [synthesis; the source does not say who chose topics].
  3. Give a short accessible talk.
  4. Open the discussion, inviting women to connect the topic to their lives.
  5. Close by noting any shared issues raised, and keep a list of issues the women want to pursue [synthesis].
• Example language (illustrative). "Today's topic is how the welfare state treats mothers on their own. I'll talk for ten minutes, then it's over to you. What fits your experience, and what doesn't?"
• Watch for.
  • Women who were silent starting to speak.
  • Shared grievances emerging, which are the seeds of social action.
  • The talk turning into a lecture. If so, shorten it [synthesis].

4.6 Identity-based history group (Afro-Caribbean Women's History Group)

• Purpose and when to use. Stage 3, for women who share an ethnic and migration history. In Holland's group, women's personal losses, often tied to troubled relationships with their own mothers, were placed within colonialism, imperialism, immigration and racism. The emphasis was on the women's shared sense of suffering and loss. Holland framed this as Freire's conscientisation [source: Holland, Self & Society].
• Steps [synthesis]:
  1. Form the group with women of the shared background.
  2. Wherever possible, involve a facilitator or co-facilitator from that community.
  3. Move between members' accounts of family separations, including mothers who migrated ahead of them and children left with relatives, and the history that shaped those separations.
  4. Draw out what is common and what strengths the group shares.
• Example language (illustrative). "Several of you were left with grandmothers when your mothers came to England. What did that history do to mothers and daughters?"
• Watch for.
  • A white or outsider facilitator speaking for the group.
  • Retraumatising detail being pressed for.
  • Signs it is working: the sense of being personally bad shifts towards shared grief and solidarity [synthesis].

4.7 Themed issue group ("Mixed Blessings")

• Purpose and when to use. Stage 3, for women who share a life situation. Holland's "Mixed Blessings" group was for women living in relationships with, and raising children with, men from other cultures [source: Holland, Self & Society].
• Steps [synthesis]:
  1. Define the shared situation with the women.
  2. Run regular sessions in which members bring current dilemmas, such as children's identity, family reactions, racism and immigration status.
  3. Separate what belongs to the couple from what external forces impose.
• Example language (illustrative). "How much of the strain in your marriage comes from the two of you, and how much from the Home Office and the neighbours?"
• Watch for.
  • Pressure on members to conform to a group line about their partners.
  • Domestic-abuse disclosures that need individual follow-up [synthesis].

4.8 Confidential personal-therapy group on marriage and sexual relationships

• Purpose and when to use. Stage 3, a more therapeutic group. It is confidential, but it also considers political pressures on relationships such as immigration rules. Holland reports women's experience of marriages ending because partners seemed to want a British passport. The groups asked why that was treated as worse than "romantic love", and looked at how Home Office decisions could damage relationships. They also questioned romantic love as a cultural ideal and what being "loved" means [source: Holland, Self & Society].
• Steps [synthesis]:
  1. Agree confidentiality rules and their limits, including safeguarding, at the start.
  2. Use a closed membership and a regular time.
  3. Explore members' relationship experiences, and link personal hurt to cultural ideals and state rules where it fits.
• Example language (illustrative). "We're told a marriage should be pure romance. What does being loved actually mean to each of you?"
• Watch for.
  • Shame about relationships that are judged "for papers".
  • Abuse, coercive control or immigration-related coercion, which needs safeguarding and specialist immigration advice.
  • Signs it is working: members re-evaluate self-blame for failed relationships [synthesis].

4.9 Supporting collective social action and self-organisation

• Purpose and when to use. Stage 4. Women from the study-group discussions set up their own structure to tackle estate issues. They won Greater London Council (GLC) funding and ran their own centre, Women's Action for Mental Health [source: Holland, Self & Society]. The aim is collective action against the structures that sustain shared oppression [source: Wikipedia summarising Holland 1992].
• Steps [synthesis; the sources give the outcome, not a procedure]:
  1. Keep the shared issues the groups have raised visible.
  2. Ask whether the women want to act on any of them.
  3. Help them plan concrete, winnable actions: a joint letter, a meeting with the housing department, a funding bid, premises.
  4. Offer skills such as minute-taking, bid writing and contacts, rather than leadership.
  5. Step back from formal roles as the women's organisation forms.
  6. Stay available as a consultant.
• Example language (illustrative).
  • "You've all said the lifts and the lack of a crèche are wearing you down. Do you want to do something about it together?"
  • "It's your group. What would you like from me?"
• Watch for.
  • Signs it is working: women chairing meetings, the organisation continuing without you, and new members arriving through it.
  • The professional's own agenda driving the action.
  • Dependence on a single funder. WAMH relied on the GLC, which was abolished in 1986 [synthesis; the abolition date is general knowledge, not from the sources].

4.10 Advocacy and accompanying

• Purpose and when to use. By 2005 this was documented as a main strand of the project's work, alongside one-to-one counselling: advocacy, and accompanying women to hospitals and courts [source: Chaplin 2005]. Use it when a woman faces an institution alone at a point of crisis.
• Steps [synthesis]:
  1. Agree with the woman what she wants from the appointment, and what you will and will not say.
  2. Accompany her, helping her to speak for herself where she can.
  3. Debrief afterwards and link the experience to the therapy.
• Example language (illustrative). "I'll be next to you. You do the talking, and if you look at me I'll help you get your point across."
• Watch for.
  • The boundaries of a dual role. Agree how this affects therapy confidentiality.
  • Her capacity to self-advocate growing [synthesis].

4.11 Using the paradigm "square" for formulation and review

• Purpose and when to use. Holland's model places each stage in one of Burrell and Morgan's four quadrants: functionalist, interpretive, radical humanist and radical structuralist [source: Wikipedia]. Using the square as a working tool for case review is a derived application [synthesis].
• Steps [synthesis]:
  1. At each review, place the client's current work in a quadrant.
  2. Ask whether she wants to move on or stay.
  3. Check that the service offers something in each quadrant. If it offers only medication and one-to-one work, it is confined to the individual-change row.
• Example language (illustrative). For a team: "Most of our caseload sits in the individual-change row. What would it take to offer a group?"
• Watch for. Using the square to push clients along against their wishes [synthesis].

4.12 Contemporary adaptation note (not Holland's model)

A current NHS example of related community psychology is Tower Hamlets Community Psychology (East London NHS Foundation Trust). It is not presented as Holland's model, and it does not cite her [source: ELFT case study]. Its methods include:

• groups co-produced with community partners;
• consulting women who were not engaging with services, and treating services, not the women, as the barrier;
• open, flexible weekly sessions, such as an 8-week, 2-hour gardening group;
• cooking and shared recipes using the Recipes of Life method;
• a sociogram recording how each member found the group;
• members writing a joint letter to politicians about GP access.

Clinicians adapting Holland's model today may borrow these. Treat them as an analogue [synthesis].

5. Handling problems

Holland's account names only a few problems: severe depression blocking participation, therapy that individualises, heavy reliance on medication, and the pressures of immigration and racism. Chaplin (2005) adds that the social-action aim faded over time. Everything else below is [synthesis].

• Too depressed to attend groups or act (source-based). Stay in individual work until the depression lifts. Do not treat non-attendance as resistance [source: Holland, Self & Society]. If there is no improvement, review risk, consider a psychiatric or medication review with the prescriber, and look at practical barriers such as childcare, fares and safety on the estate [synthesis].
• Therapy is individualising the woman (source-based). Holland's own warning is that therapy can be reductive or reactionary [source: Holland, Self & Society]. If a client keeps concluding "it's all my fault", bring in the social side (4.4) and offer a group [synthesis].
• Medication is all the woman expects (source-based). Holland worked against reliance on "pharmacological solutions" [source: Holland, Self & Society]. Respond by exploring meaning, never by advising her to stop. Any change goes through the prescriber, and her choice to stay on medication is respected [synthesis].
• Immigration and racism dominate (source-based). Address them directly in identity-based groups [source: Holland, Self & Society]. Refer to an immigration adviser or solicitor for anything legal. Do not give legal advice [synthesis].
• The social-action stage does not happen or fades (source-based). By 2005 the project was mainly doing one-to-one counselling and advocacy. Chaplin linked the earlier social action to the optimism and the central and local government resources of the early 1980s [source: Chaplin 2005]. Respond in three ways [synthesis]:
  • Treat symptom relief as a valid endpoint [source: Wikipedia].
  • Aim for small, concrete collective actions rather than a full organisation.
  • Build ties with existing tenants' groups, women's centres and community organisations instead of founding new ones.
• The client only wants symptom relief (source-based). That is a legitimate outcome [source: Wikipedia summarising Holland 1992]. End well and leave the door open to groups.
• Rupture over the political frame [synthesis]. The client feels lectured, or feels her personal pain has been turned into politics. Acknowledge it and apologise for running ahead of her. Return to her account and offer the social reading only as a question.
• Resistance that is really realistic mistrust [synthesis]. Women may distrust NHS staff because of social services, child protection or immigration enforcement. Be explicit about what you record and share, and about safeguarding limits. Earn trust through reliability and practical help (4.10).
• Non-adherence: missed sessions or dropping in and out [synthesis]. Expect chaotic lives. Use open-entry groups and flexible return. Send a brief, non-shaming follow-up and ask what got in the way, which is often childcare, money or a crisis.
• Overwhelm in groups [synthesis]. Shared histories of loss, colonialism or abuse can flood members. Pace the material, keep a grounding close to each session, offer individual follow-up, and never push for traumatic detail.
• Dual relationships and confidentiality on one estate [synthesis].
  • The same clinician may see a woman individually, in groups and in the community, and members are neighbours.
  • Agree at the start how you will greet each other in public.
  • Keep individual material out of groups unless she brings it.
  • Set group confidentiality rules, and accept that you cannot fully guarantee them.
  • Take dual-role questions to supervision.
• Group conflict, cliques or exclusion [synthesis]. Name the dynamic in the group and revisit the group agreement. Consider separate identity-based groups, as Holland ran. Keep a route in for newcomers.
• The professional dominates the women's organisation [synthesis]. Agree a timeline for handing over roles, decline formal office, and review your role with the members.
• Activist burnout, or exposure to backlash from authorities, landlords or partners [synthesis]. Help the women pace their action, share roles, and assess the risks of public action, especially for women with insecure immigration status or abusive partners.
• Risk and safeguarding [synthesis]. Suicide risk, domestic abuse and child safeguarding follow standard local procedures at every stage. Group work does not replace individual risk management.
• Service remit and funding [synthesis]. NHS services may not fund community development. WAMH depended on GLC money [source: Holland, Self & Society]. Respond by partnering with voluntary-sector bodies, writing the group work into service specifications, and seeking diverse funding.
• Applying the model beyond women [synthesis]. Holland's model was developed with women. Later accounts applied a similar approach elsewhere, such as Melluish and Bulmer's (1999) men's health action project (not drawn on [uncertain]). Adapt the groups to the population's own shared conditions, and do not import the women's themes unchanged.

Sources

Sources:

• Motherhood, Melancholia and Mutual Groups (Sue Holland), Self & Society 13(6):311–313. This is the primary source. Year not shown in the copy; about 1985 [uncertain].
• The Bridge Project: Radical Psychotherapy for the Twenty-First Century (Jocelyn Chaplin), Psychotherapy and Politics International 3(2), 2005
• Psychotherapy and social action model (Wikipedia). This secondary summary of Holland (1992) is the source of the four stages and the paradigm square used here.
• Community Psychology Model case study, Tower Hamlets Community Psychology, East London NHS Foundation Trust (NHS Transformation Partners, 2023). Contemporary analogue only.

Further reading (not drawn on) [uncertain]:

• Holland, S. (1992). From social abuse to social action: a neighbourhood psychotherapy and social action project for women. In J. Ussher & P. Nicolson (Eds.), Gender Issues in Clinical Psychology. London: Routledge.
• Holland, S. (1988). Defining and experimenting with prevention. In Psychiatry in Transition. London: Pluto Press. Chaplin (2005) names the editor as J. Marmor. The editors are usually given as S. Ramon and M. Giannichedda [uncertain].
• Burrell, G. & Morgan, G. (1979). Sociological Paradigms and Organisational Analysis. London: Heinemann.
• Freire, P. Pedagogy of the Oppressed. Referred to by Holland for conscientisation; not drawn on.
• Fenner, J. (1999). Our way: Women's action for mental health (Nottingham). Journal of Community and Applied Social Psychology, 9, 79–91.
• Melluish, S. & Bulmer, D. (1999). Rebuilding solidarity: an account of a men's health action project. Journal of Community and Applied Social Psychology, 9, 93–100.
• Orford, J. (2008). Community Psychology: Challenges, Controversies and Emerging Consensus. Chichester: Wiley.