SOCIAL PRESCRIBING FOR
ECOPSYCHOSOCIAL WELLBEING

Susan V. Bosak, Legacy Project

with
Dr. Kate Mulligan, Assistant Professor
Dalla Lana School of Public Health, University of Toronto
Board Member at Toronto Board of Health and 8-80 Cities

April, 2022

"I believe that the community – in the fullest sense: a place and all its living entities – is the smallest unit of health and that to speak of the health of an isolated individual is a contradiction in terms."
Wendell Berry, novelist, culture and environmental thinker

Social prescribing is a model of care at the crossroads between healthcare and community. It enables a doctor to ask: what's the community alternative to my medical intervention? It helps people get connected socially into their community.

Medical professionals care for their patients every day. Care also underlies the 7-Generation work: whether people feel cared about (through the relationships they have, especially across generations) and what they care about (what matters and means something to them, brings them a sense of purpose and direction).

With more than two decades of groundwork, the 7-Generation initiative starting in Markham is a systems approach to wellbeing in lifetimes across generations. The community collaborative includes the Legacy Project, the City of Markham, Markham Public Library, Social Services Network, and York University.

SOCIAL DETERMINANTS PLUS

When someone enters a doctor's office, what ails them is often beyond the simple physical. The social determinants of health from the Canadian Institute for Health Information, the factors that make the biggest difference in people's health, in order of impact are:

1. Income Status
2. Education
3. Social Support Networks
4. Employment and Working Conditions
5. Early Childhood Development
6. Physical Environment
7. Personal Health Practices and Coping Skills
8. Biological and Genetic Factors
9. Health Services
10. Gender
11. Culture
12. Mass Media Technology (i.e. TV viewing, physical inactivity)

In addition to these social determinants, the 2021 Toronto Vital Signs Report indicates people's perception of both their physical and mental health has declined over the last couple of years. "Experts are warning of the long-term implications of the pandemic on our mental and physical wellbeing, and the far-reaching impacts into other aspects of our lives."

Then layered on top of all of this, we're also seeing what might generally be termed "existential angst" – from social unrest to ecoanxiety. People are worried about where the world is going and their futures in it.

In the concerning context of increasingly polarized views, misinformation and disinformation, we need more community-based approaches. Trust opens minds, relationships heal, and human connection helps us thrive. Dr. Kate Mulligan, who led the social prescribing pilot in Ontario, has called on public health units to help communities "stay healthy, safe, savvy and included in decisions. We need to repair trust, organize communities, and prevent future worsening of divisions."

There's no pill for any of this.

SOCIAL PRESCRIBING

Doctors are clearly limited in what they can do. Social prescribing is a community-based pathway for helping move from "What's the matter with you?" to "What matters to you?"

Mulligan suggests that "with the new rollout of the Ontario Health Teams (OHTs), there is an opportunity to weave social prescribing into the tapestry of our healthcare system."

Social prescribing has gained widespread recognition in the UK with prominent figures in their healthcare system pioneering the change. Hear from the "godmother" of social prescribing in the UK, General Practitioner Dr. Marie Anne Essam, about her experiences with social prescribing and how she suggests healthcare providers can get involved:

The Alliance for Healthier Communities has worked to bring social prescribing to Canada.

From 2018 to 2020, the Alliance implemented Rx: Community – Social Prescribing, the first-in-Canada social prescribing research project. This pilot project was comprised of 11 Alliance member organizations, including urban, rural, and Francophone centres from across Ontario. This project emphasized the importance of an asset-based approach. Social prescribing navigators connected clients to their social prescriptions through a co-design process that highlighted the clients' goals and gifts.

From the final report on the social prescribing pilot: "What does it take for the healthcare system to truly integrate clinical and social care and to fully support the physical, mental, and social health and wellbeing of each person?… We know that as much as 80-90% of our health outcomes are driven by the social determinants of health. For a person to thrive in health and wellbeing, they must have access not only to appropriate clinical care and material supports, but also to meaningful social support and a community where they feel they belong… Social prescribing may look different in different communities, depending on local needs and capacity… During the pilot clients reported overall improvements to their mental health and a greater capacity to self-manage their health, as well as decreased loneliness and an increased sense of connectedness and belonging. Healthcare providers find social prescribing useful for improving client wellbeing and decreasing repeat visits."

Social prescribing empowers clients to improve their health by developing new skills participating in meaningful activities, and becoming more connected to their communities. As an asset-based approach, social prescribing recognizes people as not just patients with needs, but community members with gifts to share.

Says Mulligan, in an article on social prescribing, "Going from seeing yourself as someone with an illness to seeing yourself as a gift, with something to offer, is really transformative… It gives you a feeling of more control of your health and wellbeing."

In partnership with the Older Adult Centre's Association of Ontario (OACAO), the Alliance is building on the success of Rx: Community with a new project, Links2Wellbeing. Links2Wellbeing aims to transform the way healthcare providers link older adults in Ontario to social and recreational opportunities to promote holistic health and wellbeing.

INTERGENERATIONAL CONNECTEDNESS

Caring connections underly the 7-Generation work. From a Government of Ontario report Connected Communities: "Being socially connected to family, friends, and our communities – having a sense of belonging – is important to our wellbeing. People who are connected are happier. They enjoy better health and use fewer health services. They are more resilient in the face of adversity, and they live longer. Communities where people feel connected have less crime and stronger economic growth… Their citizens are more involved; they are more likely to co-operate to benefit all members of the community… Our sense of community is threatened by large systemic pressures and changes. These large systemic pressures require system-wide solutions."

All generations in communities are challenged by a lack of connectedness and belonging. Even before COVID-19, we know more children and youth were experiencing mental health issues, feeling stress and a lack of hope, and struggling to find a place in the economic and social fabric of society (since jobs are so closely tied to a sense of self and wellbeing). At the other end of the age spectrum, care needs for frail elders are increasing; we live in a highly ageist and age-segregated culture; as we get older society tends to marginalize us; and over 30% of Canada's older adults are at risk of social isolation.

Anthropologist Margaret Mead asserted that "connections between generations are essential for the mental health and stability of nations."

How do our institutions and culture encourage or discourage the relationships humans need? From A Portrait of Social Isolation and Loneliness in Canada Today: "The default response to a problem like loneliness and social isolation is to focus on solutions. We want to 'fix it' and are tempted to look for the five-step formula that promises to eradicate them. While not dismissing the possibility that some immediate steps may mitigate the situation for some sufferers, rising loneliness and social isolation are complex phenomena that resist easy fixes. We must recognize that they arise from deeper and structural issues in society. We don't expect to solve loneliness and social isolation through a platform of policy proposals or moralistic prescriptions… Human relationships are not simply connections between two individuals. They take place within a social context. Our institutions and culture either encourage or discourage the sorts of relationships that meet human needs."

So here's the practical question: Why do we routinely address the problems of children and older adults separately, when often the two ends of the age spectrum have similar or complementary needs that can be more effectively addressed through a single intervention that addresses multiple issues in a more cost-efficient manner?

The 7-Generation work takes a systems approach around the dynamic of intergenerational relationships in the context of place. It explores what matters in the big-picture context of lifetimes across generations. Young and old form relationships in community, learning from and with each other around what's important to them. By strategically connecting elders and youth, we can improve their mutual wellbeing while sparking far-reaching impact. Research shows that intergenerational relationships can bridge silos and issues, and can also help bridge gender, racial, socioeconomic, and ideological divides.

In addition to the community collaborative and local partners (e.g. medical practices), we also have a Group of Seven big-picture advisors. Dr. Peter Whitehouse is part of the Group of Seven, and is a neurologist who helped found The Intergenerational School (TIS) in Cleveland, OH.

TIS received the 2014 Eisner Prize. The TIS model is informing the Elders-in-Residence part of 7-Generation Markham. Interested older adults can become part of their neighbourhood school, interacting with students, teachers, and parents on a regular basis.

At TIS, students are grouped by age clusters rather than grade, and elders (even those with cognitive or physical limitations) are woven into the fabric of the school day such that young and old learn from and with each other across the curriculum. The public charter school is connected by a walkway to an older adult housing complex. A video introduction to the school highlights its unique characteristics.

Research conducted on the school has shown that students have higher levels of academic achievement, higher graduation rates, as well as better mental health, behavioural and social skills.

In terms of the older adults, Whitehouse shares the story of Mrs. Kelsey, who volunteered regularly every week at the school, working with the same class of 17 students on each visit. She would be brought to the school by a caregiver and walk slowly to the classroom to meet the children. Like all of the school's older volunteers, she interacted with students individually on small couches in the hall, reading stories with children, asking them questions about plot and character, and laughing at their frequent quips and comments. Over time, she got to know the teacher and the class well and, as she read books each week, she formed close bonds with some of the children in greatest need of love and attention. She would listen closely and encourage them to pick their own books and take charge of their own learning. At times, they would skip reading altogether and share stories from their own lives.

Mrs. Kelsey was so loved, so engaged, and so reliable that she was selected as a TIS "Volunteer of the Year." While waiting to go on stage to receive her award, she turned to her daughter and asked why she was getting the award. Her daughter reminded her that she visited the school to volunteer each week and was so appreciated because she helped the children learn to read and love books. Mrs. Kelsey expressed her surprise at this news: her short-term memory loss was so severe that she could not remember her own visits to the school, but the school's caring environment reinforced her remaining strengths and met her – non-judgmentally – where she was.

Whitehouse explains, "For older adults, the results are significant as they become a vital part of our school community. There are health benefits of less depression, more purpose and meaning, and the elders know they can count on staff and students for help and support when they need it. Once older adults begin at the school, they attend the school weekly and stay with us for years, often even staying in touch with students once they graduate."

Young and old can certainly be a gift to each other, which is the premise of the 7-Generation work.

HOW DOES IT WORK?

We're working with healthcare professionals to co-create the community interface for a Wellbeing Path.

We've had some candid conversations so far. Reported one social services provider, "I've never been on the phone with so many people crying. We need genuine, caring, vital human relationships. If we don't have a strong social fabric, we have nothing."

Under the social prescribing model, healthcare professionals can refer anyone they wish. Although we do not provide acute mental health supports, we can support people of all ages, in particular older adults, who may be experiencing loneliness, social isolation, general anxiety and concern.

We're working on an evaluation component so that we can effectively report on and evolve the Wellbeing Path. But people who connect with us aren't "assessed;" they are welcomed. A trained Guide chats with a person and gets a feel for where they're at and what they might be interested in. The focus throughout is on relationship, especially across generations – what we call threads, which ultimately help reweave the social fabric.

Can we move beyond a focus on delivering programs/services to a focus on relationships to be nurtured? In other words, forget programs and symptom change. Pay attention to relationships and systems change. Vitality in a living system (let's use ecological systems as a model) is about relationships upon relationships. It's the connections that are important. Meaning arises through our connectedness – connectedness within ourselves (lives), to other people of all ages (community), and to the entire living world (the planet). This puts empowering people and building community capacity ahead of imposed program design and delivery.

In Western culture, too often we skip directly to action. In keeping with Indigenous approaches, the 7-Generation work starts in respect (listening; ears/eyes), flows into connect (relationship; heart), then to reflect (thinking; mind), and only then direct (action; hands). It's about responding authentically without preconceived constraints.

We're leveraging libraries and schools (existing infrastructure found in every neighbourhood) to grow a neighbourhood-based network of threads. This collectively organizes for neighbourhood-level caring and change in ways that, over the long term, also strengthen and mobilize larger community systems in a human/e and meaningful way.

Although different from the Wellbeing Path work, the example of contagious caring helps illustrate the potential: "Community life starts in acquaintances, fueled by simple conversation. After repeated sharing of ideas and opinions, these eventually grow into friendships. Finally, deeper convictions and feelings are shared, producing an intimacy that makes people more vulnerable and more interlinked and trusting… Most social-improvement efforts are undermined by a failure to build the healthy relationships they require – relationships are the necessary foundation for things like safety, good neighboring… Once people realize the power of relationships, they can move their communities to higher levels of wellbeing."

As part of the Wellbeing Path, people can choose to participate in virtual and in-person events, learning from and with each other. They have an opportunity to talk with people of all ages and backgrounds, people they may not otherwise meet. They can form one-on-one relationships. They can explore different topics of interest to them.

To facilitate the relationship-building process, the Legacy Project has developed the Listen to a Life Contest, Legacy Links, and a wide variety of intergenerational, learning, and legacy activities. With the support of the local library, books are a key part of relationship-building and conversation. We also have Warm Data events (a thought-provoking format that helps participants make connections between each other and across different contexts, developed by Nora Bateson at the International Bateson Institute in Sweden) and even legacy projects as a way to make a difference in the community. Everyone participating becomes a community sensemaker – a process that gives them an opportunity for self-reflection and a chance to connect their personal life stories to the stories of others locally and globally (we're working with the Cynefin Centre in the UK using their SenseMaker software).

Each person will find their own pathway through the opportunities.

WELLBEING IN COMMUNITY

Wellbeing for all generations goes beyond simple structural issues to the ecopsychosocial foundation of our society – who we are, what we value, how we live with each other on a changing planet.

From a systems perspective, we don't have a healthcare crisis, or a youth mental health crisis, or a seniors social isolation crisis, or even a loneliness crisis – we have a village crisis.

One of the limitations of the social prescribing model is that simply referring people to social activities in the community is to address the symptoms of a social 'dis-ease' without creating genuine pathways toward enriching life experiences in a meaningful community. The Wellbeing Path is ultimately trying to address the latter.

In practical terms, community is a verb. And care isn't an institutional intervention or a service (though both are important in certain circumstances). Care is a vital human interchange, in the context of interdependence, that can't really be prescribed – it is a gift of the heart.

This goes back to seeing yourself not as someone with an illness, but someone with gifts to offer. The other side of that, from the perspective of the Wellbeing Path, is welcoming someone in a way that says, "You matter to us. We can't do this without you. We need you and we need your gifts. Don't worry about your limitations; we all have them. We'll work with who and where you are. You can participate in your own unique way and contribute your gifts on your terms. Let's go!"