Introduction to Community Psychology Handout
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This handout provides an introduction to the field of community psychology. It discusses the definition, objectives, overview, and recurring themes of the subject. The handout also clarifies the difference between prevention and treatment in the context of the medical model, with an emphasis on the emergence of community psychology in the 1960s. The role of community psychologists is highlighted, along with the importance of considering context and social factors, and the goals and values in community psychology.
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**I. INTRODUCTION TO THE FIELD OF COMMUNITY PSYCHOLOGY**[^1^](#fn1){#fnref1.footnote-ref} **Objectives:** At the end of the discussion the students are able to **I. Overview** Reflect on these questions: - What is a psychologist? - Where do psychologists often work? The *medical model* pre...
**I. INTRODUCTION TO THE FIELD OF COMMUNITY PSYCHOLOGY**[^1^](#fn1){#fnref1.footnote-ref} **Objectives:** At the end of the discussion the students are able to **I. Overview** Reflect on these questions: - What is a psychologist? - Where do psychologists often work? The *medical model* presupposes that it involves a therapist delivering one-on-one psychotherapy with an individual. In the medical field, it would involve a physician fixing a patient's broken arm of administering an antibiotic. Although there is a clear need for this traditional model for those with medical or psychological problems, many do not have access to these services, and a very different approach will be required to successfully solve many of the individual and community problems that confront us. - 1960s Community Psychology emerged in the United States in response to the social conditions at that time: protests, demonstrations, urban unrest, and intense struggles over issues such as the Vietnam War and the Civil Rights Movement. Many psychologists wanted to find ways to help solve these pressing societal issues, and some therapists were becoming increasingly disillusioned with their passive role in solely delivering the medical model, office-based psychotherapy (as cited by the editors from Cowen, 1973). - 1965 the term 'community psychology' was coined at the Swampscott Conference in the US and new roles of psychologists emerged: extending the reach of services to those who had been under-represented, focusing on prevention rather than just treatment of psychological problems, and by actively involving community members in the change process (as cited by the editors from Bennett et al., 1966). Prevention vs. Treatment ![Continuum of Care](media/image2.jpeg) Reference: Example of a Treatment and Prevention Program from the Lancet Psychiatry Journal (2016) Prevention, early intervention, harm reduction, and treatment of substance use in young people - The Lancet Psychiatry - Recurring themes in Community Psychology; prevention, social justice, and an ecological understanding of people within their environments. II\. Community Psychology - *Definition:* **Community psychology concerns the relationships of individuals with communities and societies. By integrating research with action, it seeks to understand and enhance quality of life for individuals, communities, and societies.** - Community psychology is also committed to developing valid psychological knowledge that is useful in community life. In the community psychology perspective, knowledge is constructed through action. The community psychologist's role has often been described as that of a *participant--conceptualizer* (Bennett et al., 1966, pp. 7--8), actively involved in community processes while also attempting to understand and explain them. - *The goal of community psychology:* to examine and better understand complex individual--environment interactions in order to bring about social change, particularly for those who have limited resources and opportunities. - Compared to other psychological fields, community psychology involves a shift in perspective. The focus of community psychology is not on the individual alone but on how the individual exists within a web of contexts---encapsulating environments and social connections. Persons and social contexts influence each other. Discounting the influence of social contexts is the *context minimization error.* - Some of our most important assumptions about problems concern the importance of persons and contexts. Shinn and Toohey (2003) coined the term context minimization error to denote ignoring or discounting the importance of contexts in an individual's life. Context (a term we will use throughout this book) refers to the encapsulating environments within which an individual lives (e.g., family, friendship network, peer group, neighborhood, workplace, school, religious or community organization, locality, cultural heritage and norms, gender roles, social and economic forces). Together, these make up the structural forces that shape the lives of individuals. ***Context minimization errors lead to psychological theories and research findings that are flawed or that hold true only in limited circumstances**.* These errors can also lead to therapy interventions or social programs that fail because they attempt to reform individuals without understanding or altering the contexts within which those individuals live (Kloos et. al, 2012, p. 11). - Community psychologists seek to understand people within the social contexts of their lives and to change contexts in order to promote quality of life for persons (Kloos et. al, 2012, p. 12). Recurring Theme: The Role of Prevention - One of the primary characteristics of the Community Psychology field is its focus on preventing rather than just treating social and psychological issues, and this can occur by boosting individual skills as well as by engaging in environmental change. - a key prevention theme in the field of Community Psychology, and in this case, the preventive perspective involved getting to the root of the problem and then securing buy-in from the community in order to secure resources necessary to implement the changes - Two radical ways of bringing about change *First order change:* attempts to eliminate deficits and problems by focusing exclusively on the individuals. *Second order change: identifying the root/real causes of the problem,* --------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- *Examples: band aid solutions, individual solutions* *Examples: identifying the root cause of a problem, enlisting social support for patients and not just individual treatment; changing schools to provide contexts of productive learning for all students, changing systems for recovery from substance abuse, and empowering young mothers.* - *First-order change alters or replaces individual members of a group or community; second-order change alters the role relationships among those members. For social and community issues, problems are not "solved" but changed. Every action creates new challenges, but these can be an improvement over time.* - There is a considerable appeal for a preventive approach, particularly as George Albee (1986) has shown that no condition or disease has ever been eliminated by focusing just on those with the problem. - Prevention is also strongly endorsed by those in medicine who have been trained in the Public Health model, where services are provided to groups of people at risk for a disease or disorder in order to prevent them from developing it. - Public Health practitioners seek to prevent medical problems in large groups of individuals through, for example, immunizations or finding and eliminating the environmental sources of disease outbreaks. Community Psychology has adopted this preventive Public Health approach in its efforts to analyze social problems, in addition to its unique characteristics. - Policies that emerge from concerned individuals, community activists, and coalitions are referred to as bottom-up approaches to second-order change. Community psychologists have clear roles to play in dialoguing and collaborating with community groups in these types of broad-based, preventive community change efforts. *Recurring Theme: A Social Justice Orientation* - *Community Psychology's focus on social justice is due to the recognition that many of our social problems are perpetuated when resources are disproportionately allocated throughout societies; this causes social and economic inequalities such as poverty, homelessness, underemployment and unemployment, and crime.* - *Studies have shown that:* *Albee (1986) has concluded that societal factors such as unemployment, racism, sexism, and exploitation are the major causes of mental illness.* ![](media/image6.jpeg)[^2^](#fn2){#fnref2.footnote-ref} *Richard Wilkinson and Kate Pickett's (2009) book The Spirit Level documents how* *many health and social problems are caused by large inequalities throughout our societal structure. Economic inequalities not only cause stress and anxiety but also lead to more serious health problems. Studies of income inequality have shown how adult incomes have varied by race and gender, and this link allows you to make comparisons that provide animations for any combination of race, gender, income type, and household income level.* *In the United Kingdom, the link between poverty and mental health has been recognised for many years and is well evidenced. In general, people living in financial hardship are at increased risk of mental health problems and lower mental wellbeing. It is well established that people in the lowest socioeconomic groups have worse mental health than those in the middle groups, who in turn have worse mental health than those in the highest. This 'social gradient' means that mental health problems are more common further down the social ladder. (Kousoulis et. al, par. 6, 2020).*[^3^](#fn3){#fnref3.footnote-ref} - *Community Psychology endorses a social justice and critical psychology perspective which looks at how oppressive social systems preserve classism, sexism, racism, homophobia, and other forms of discrimination and domination that perpetuate social injustice (Kagan, 2011). Clearly, there is a need to bring about a better society by dismantling unjust systems such as racism. In addition to identifying and combating systems that are unjust, community psychologists also challenge more subtle negative practices supported by psychological research and practice.* - *Traditional mental health services such as therapy that deals with a student's mental health issues would not address the income resource inequalities and stressful environmental factors that could be causing children's mental health difficulties. Second-order change strategies, in contrast, would address the systems and structures causing the problems and might involve collaborative partnerships* *Example:* example, Zimmerman and colleagues investigated what it takes to cultivate - According to an individualist perspective, people end up in prison because of - There is now considerable basic laboratory research that indicates that context or environment can have a shaping influence on the lives of humans and animals. For example, laboratory rats who are raised in "enriched" environments show brain weight increases of 7-10% (heavier and thicker cerebral cortexes) in comparison to those in "impoverished" environments (Diamond, 1988). - There was a time when scientists did not believe that the brain could be changed by any environmental enrichment, but it is now commonly accepted that context can have a lasting and shaping influence on our behavior and even our brains. We need to attend to the environments of those living in poverty and exposed to high levels of crime, as these factors are associated with multiple negative outcomes including higher rates of chronic health conditions. **III. A Shift in Perspective: The Ecological Model (Olya Glantsman)** - An aspect of Community Psychology that sets it apart from a more traditional Clinical Psychology is a shift beyond an individualistic perspective. Community psychologists consider how individuals, communities, and societies are interconnected, rather than focusing solely on the individual. As a result, the context or environment is considered an integral part when trying to understand and work with communities and individuals embedded in them. - This shift in thinking is referred to as an ecological perspective - Ecological: Ecological means that there are multiple levels or layers of issues that need to be considered, including the individual, family, neighborhood, community, and policies at the national level. - Difficult and complex social problems are produced and maintained by multiple ecological influences and corrective second--order community solutions will have to deal with these contextual issues. - Community Psychologists study ecological levels of analysis. Individuals interact within such microsystems as families, friendship networks, classrooms, and small groups. Microsystems often are nested within such organizations as schools and workplaces. Microsystems and organizations may exist in specific localities, such as neighborhoods. All these systems exist within such macrosystems as societies and cultures. Microsystems are the most proximal (closest) level to individuals, while macrosystems are the most distal---but all influence individual lives. A setting is an enduring set of relationships among individuals that may be associated with one or several physical places. It may apply to microsystems or to organizations. - James Kelly (2006): Principles to better understand how social environments affect people a\. Ecological Principle of Interdependence - indicates that everything is connected, so changing one aspect of a setting or environment will have many ripple effects. For example, if you provide those released from prison a safe place to live with others who are gainfully employed (as occurs in Oxford Houses), this setting can then lead to positive behavior changes. - Living among others in recovery provides a gentle but powerful influence for spending more time in work settings in order to pay for rent and less time in environments with high levels of illegal activities. - Indicates that behavior adaptive in one setting may not be adaptive in other settings. A person who was highly skilled at selling drugs and stealing will find that these behaviors are not adaptive or successful in a sober living house, so the person will have to learn new interpersonal skills that are adaptive in this recovery setting. - The ecological perspective broadens the focus beyond individuals to include their context or environment, by requiring us to think about how organizations, neighborhoods, communities, and societies are structured as systems. - The three main areas of adaptive behavior are:[^4^](#fn4){#fnref4.footnote-ref} Conceptual skills: These set of skills include academics, communication skills Social skills: These are interpersonal skills, self-esteem, adhering to rules, etc. Practical skills: These comprise basic skills like self-grooming, hygiene, managing the home, taking care of one's health and safety, etc. **IV. Seven Core Values in Community Psychology**[^5^](#fn5){#fnref5.footnote-ref} Values (definition) - Values are deeply held ideals about what is moral, right, or good - the regard that something is held to deserve; the importance, worth, or usefulness of something (Oxford Languages, 2021) Characteristics of Values - They have emotional intensity; they are honored, not lightly held. - Values may concern ends (goals), or means (how to attain goals), or both. - They are social; we develop values through experiences with others. - Individuals hold values but so do families, communities, and cultures. - Values may be rooted in spiritual beliefs or practices but can also be secular. Many values conflicts involve choices about which of two worthy values is more important in a given situation (Nelson & Prilleltensky, 2010; O'Neill, 1989; Rudkin, 2003; Schwartz, 1994; Snow, Grady, & Goyette-Ewing, 2000). Purpose of Values for Community Psychology/Psychologists 1\. *Values help clarify choices for research and action.* Even defining a problem is a value-laden choice, strongly influencing subsequent action (Seidman & Rappaport, 1986). Public definitions of community and social problems reflect the worldviews of the powerful and help to maintain the status quo. Attending to values can lead to questioning those dominant views. For community psychologists, deciding whether to work with a particular organization or community requires attention to values. Sometimes, the community psychologist may conclude that his or her values do not match those of a setting and choose not to work in that setting (Isenberg, Loomis, Humphreys, & Maton, 2004). 2\. *The discussion of values helps to identify when actions and espoused values do not match.* Consider a community leader who helps to found a neighborhood social center to empower teens who are gay, lesbian, bisexual, or questioning their sexuality. The leader decides how to renovate the space and plans programs, allowing the youth themselves little say. Despite the leader's intent, this actually disempowers the youth (Stanley, 2003). The leader "talks the talk" but does not "walk the walk." 3\. *Understanding a culture or community involves understanding its distinctive values.* For example, Native Hawai'ian cultural conceptions of health are closely tied to values of 'ohana and lokahi, family and community unity, and of interdependence of the land, water, and human communities. A health promotion program in Native Hawai'ian communities needs to be interwoven with these values (Helm, 2003). In the Cordillera culture, the term *'inayan'* deeply guides families and traditions. *4. Community psychology has a distinctive spirit* (Kelly, 2002a)---a shared sense of purpose and meaning. That spirit is the basis of our commitment and what keeps us going when obstacles arise (Kelly, 2010). It is thoughtful but also passionate and pragmatic, embodied in research and action. ![](media/image9.jpeg)A. Individual and Family Wellness - Wellness refers to physical and psychological health, including personal wellbeing and attainment of personal goals (Cowen, 1994, 2000a, 2000b, 2000c). Indicators of wellness include symptoms of psychological distress and such measures of positive qualities as resilience, social-emotional skills, personal wellbeing, and life satisfaction. These and similar indicators are often outcome criteria for community psychology interventions. - Strengthening families can promote individual wellness. Community prevention programs that focus on child development often address parent and family functioning. However, individual and family wellness are not synonymous. Example: when there is abuse in the family, preserving the family conflicts with an individual's mental wellness. - Community psychology goes beyond, yet complements, clinical methods by placing individual wellness in the context of ecological levels of analysis. - To promote individual/family wellness, community psychologists have studied and developed community interventions focused on the prevention of maladaptive behavior, personal and family problems, and illness; promotion of social-emotional competence and of health; social support networks and mutual help groups; intervention programs in such nonclinical settings as schools and workplaces; and advocacy for changes in social services, laws, policies, and programs to promote physical and mental health. B. Sense of Community - Sense of community is the center of some definitions of community psychology (Sarason, 1974). It refers to a perception of belongingness, interdependence, and mutual commitment that links individuals in a collective unity (McMillan & Chavis, 1986; Sarason, 1974). - Sense of community is a basis for community and social action as well as a resource for social support and clinical work. The value of sense of community balances the value of individual/family wellness. - Building a sense of community goes beyond individualism to a focus on interdependence and relationships. From a community psychology perspective, quality of life for individual and community ultimately depend on each other. - Sense of community is not always positive. It can involve distancing insiders" from "outsiders." It can be bolstered by ignoring or attacking diversity "within a community, creating injustice or a deadening conformity. It is not a cure-all. In especially risky neighborhoods, withdrawal from the community may be adaptive for adults or children (Brodsky, 1996). Thus, this value must be balanced with other values, especially social justice and respect for diversity. C. Respect for Human Diversity - This value recognizes and honors the variety of communities and social identities based on gender, ethnic, or racial identity, nationality, sexual orientation, ability or disability, socioeconomic status and income, age, or other characteristics. Understanding individuals-in-communities requires understanding human diversity (Trickett, 1996). - Persons and communities are diverse, defying easy generalizations and demanding that they be understood in their own terms. - To be effective in community work, community psychologists must understand the traditions and folkways of any culture or distinctive community with whom they work (O'Donnell, 2005a). That includes appreciating how the culture provides distinctive strengths and resources for living. - Researchers also need to adapt research methods and questions to be appropriate to a culture. This is more than simply translating questionnaires; it involves a thorough re-examination of the aims, methods, and expected products of research in terms of the culture to be studied (Hughes & Seidman, 2002). - Respect for diversity does not mean moral relativism; one can hold strong - values while also seeking to understand different values. For example, cultural traditions differ in the power they grant to women; religious traditions vary in their teachings about sexuality. Respect for diversity also must be balanced with the values of social justice and sense of community---understanding diverse groups and persons while promoting fairness, seeking common ground, and avoiding social fragmentation (Prilleltensky, 2001). To do that, the first step is usually to study diversities in order to understand them. **A related step is to respect others as fellow persons, even when you disagree.** D. Social Justice - Social justice can be defined as the fair, equitable allocation of resources, opportunities, obligations, and power in society as a whole (Prilleltensky, 2001, p. 754). It is central to some definitions of community psychology (Nelson & Prilleltensky, 2010; Rappaport, 1981). - Two meanings a\. *Distributive Justice:* concerns the allocation of resources (e.g., money, access to good quality health services or education) among members of a population). Thus, distributive justice concerns the outcomes of a program or social policy. b\. *Procedural Justice:* concerned with whether processes of collective decision making include a fair representation of citizens. Ask the reflective question: Who determines how such resources are distributed? Thus, procedural justice concerns how it is planned and implemented (Drew, Bishop, & Syme, 2002; Fondacaro & Weinberg, 2002). - A social justice perspective is often most concerned with advocacy: for social policies (e.g., laws, court decisions, government practices, regulations) and for changes in public attitudes, especially through mass media. But it can also guide clinical work with members of oppressed populations and research on psychological effects of social injustice or changes in social policy. - Social justice involves concern for wellness of all persons and an inclusive vision of community and recognition of human diversity. Procedural justice is especially related to values we present next: citizen participation in making decisions and genuine collaboration between psychologists and community members. - In practice, the pursuit of social justice must be balanced with other values and with inequalities in power that are difficult to change (Prilleltensky, 2001). E. Empowerment and Citizen Participation - Fundamental to a community psychology perspective is the consideration of power dynamics in individual relationships, organizations, and communities. - Empowerment and Citizen participation are related to procedural justice *Empowerment* - Empowerment is aimed toward enhancing the possibilities for people to control their own lives (Rappaport, 1981, 1987). - Empowerment is a process that works across multiple levels and contexts; it involves gaining access to resources and exercising power in collective decision making. *Citizen Participation* - democratic processes of making decisions that allow all members of a community to have meaningful involvement in the decision, especially those who are directly affected (Prilleltensky, 2001; Wandersman & Florin, 1990). Grassroots citizen groups, neighborhood organizations, and community-wide prevention coalitions promote citizen participation. Citizen participation also refers to the ability of a community to participate in decisions by larger bodies (e.g., macrosystems) that affect its future. - Citizen participation does not automatically lead to better decisions. Sometimes, citizens do not consider the rights and needs of all individuals or groups, and empowerment has been used to justify the strengthening of one group at the expense of another. Thus, this value must be balanced with values of sense of community, social justice, and respect for diversity. This can lead to conflict among competing views and interests. F. Collaboration and Community Strengths ![Banner collaboration and teamwork with icons](media/image11.jpeg) - The most distinctive value of community psychology, long emphasized in the field, involves relationships between community psychologists and citizens and the process of their work - Psychologists usually relate to community members as experts: researchers, clinical or educational professionals, and organizational consultants. That creates a hierarchical, unequal relationship of expert and client---useful in some contexts but often inappropriate for community work. - Psychologists also traditionally address deficits in individuals (e.g., diagnosing mental disorder), while community psychologists search for personal and community strengths that promote change. Community psychologists do have expertise to share with communities. However, they also need to honor the life experiences, wisdom, passionate zeal, social networks, organizations, cultural traditions, and other resources (in short, the community strengths) that already exist in a community. Building on these strengths is often the best pathway to overcoming problems (Maton, Schellenbach, Leadbeater, & Solarz, 2004). - Example: Appreciative Inquiry Model in Community Development Definition: AI is based on the simple assumption that every organization/community has something that works well and those strengths can be the starting point for creating positive change. This is fundamentally different from the problem-solving Deficit Approach, which focuses on the things that are not working and tries to fix them. Building the capacity of an organization or community is a fundamentally different task than fixing the old processes that are no longer working (Jakes & Miller, 2015). - The appreciative inquiry framework (see figure) builds on the strengths of the community. Rather than focusing on what is lacking, what is the weakness in the community, community facilitators ask and highlight what are things that a community is most proud of, what are the strengths that the community would like to sustain doing. - Community psychologists seek to create a collaborative relationship with citizens so community strengths are available for use. In that relationship, both psychologist and citizens contribute knowledge and resources, and both participate in making decisions (Kelly, 1986; Prilleltensky, 2001; Tyler, Pargament & Gatz, 1983). For example, community researchers may design a study to meet the needs of citizens, share research findings with citizens in a form that they can use, and help use the findings to advocate for changes by decision-makers. Developers of a community program would fully involve citizens in planning and implementing it. - Collaboration is best pursued where psychologist and community share common values. Thus, it is crucial for community psychologists to know their own values priorities and to make careful choices about with whom to ally in the community. It also means that differences in views that emerge must be discussed and resolved fairly. G. Empirical Grounding - This value refers to the integrating research with community action, basing (grounding) action in empirical research findings whenever possible. This uses research to make community action more effective and makes research more valid for understanding communities. Community psychologists are impatient with theory or action that lacks empirical evidence and with research that ignores the context and interests of the community in which it occurred. - Community psychologists use quantitative and qualitative research methods. Community psychologists prize generating knowledge from a diversity of sources, with innovative methods (Jason, Keys, Suarez-Balcazar, Taylor, & Davis, 2004; Martin, Lounsbury, & Davidson, 2004). - Community psychologists believe no research is value-free; it is always influenced by researchers' values and preconceptions and by the context in which the research is conducted. Drawing conclusions from research thus requires attention to values and context, not simply to the data. This does not mean that researchers abandon rigorous research but that values and community issues that affect the research are discussed openly to promote better understanding of findings. ***References:*** *Google Dictionary (2021). Values. In Google dictionary. Retrieved Augustt 5, 2021 from* [*https://languages.oup.com/google-dictionary-en/*](https://languages.oup.com/google-dictionary-en/) Jakes, S. & Miller, J. (2015). *Appreciative inquiry: Solving our problems by looking at what is going right.* Retrieved August 5, 2021 from Jason, L.A. et.al (editors) *Introduction to the field of community psychology.* Creative Commons Attribution 4.0 International License. Kloos, B. et. al (2012). Community Psychology: Linking Individuals and Communities. (3rd ed.). USA: Cengage Wadworth Learning. *Kousoulis, A. et.a; (2020). The COVID-19 pandemic, financial inequality and mental health.* *Image references are cited as footnotes in this handout* *Prevention, early intervention, harm reduction, and treatment of substance use in young people* *Dr Emily Stockings, PhD* *Prof Wayne D Hall, PhD* *Prof Michael Lynskey, PhD* *Katherine I Morley, PhD* *Nicola Reavley, PhD* *Prof John Strang, MD* *Published:February 18, 2016DOI:https://doi.org/10.1016/S2215-0366(16)00002-X ret.August 17, 2021* *OECD (2011), How\'s Life?: Measuring well-being, OECD Publishing.* *[http://dx.doi.org/10.1787/9789264121164-en retrrieved August 17](http://dx.doi.org/10.1787/9789264121164-en%20retrrieved%20August%2017), 2021* ::: {.section.footnotes} ------------------------------------------------------------------------ 1. ::: {#fn1} Instructor's notes from the article: Jason, L.A. et.al (editors) *Introduction to the field of community psychology.* Creative Commons Attribution 4.0 International License. Image reference: http://clipart-library.com/mental-therapist-cliparts.html[↩](#fnref1){.footnote-back} ::: 2. ::: {#fn2} Image reference: https://cultureforsolidarity.eu/on-the-meaning-of-social-justice[↩](#fnref2){.footnote-back} ::: 3. ::: {#fn3} Antonis Kousoulis, Shari McDaid, David Crepaz-Keay, Susan Solomon, Chiara Lombardo, Jade Yap, Lauren Weeks, Chris O'Sullivan, Rachel Baird, Richard Grange, Toni Giugliano, Lucy Thorpe, Lee Knifton, Mark Rowland (from the Mental Health Foundation); Tine van Bortel (from the University of Cambridge); Ann John, Sze Lee (from Swansea University); Alec Morton (from Strathclyde University); Gavin Davidson (from Queen's University Belfast)[↩](#fnref3){.footnote-back} ::: 4. ::: {#fn4} Chegg Inc. (2021). "Adaptive Behaviors Overview.:https://www.chegg.com/learn/psychology/introduction-to-psychology/adaptive-behaviors[↩](#fnref4){.footnote-back} ::: 5. ::: {#fn5} Kloos, B. et. al (2012). Community Psychology: Linking Individuals and Communities. (3^rd^ ed.). USA: Cengage Wadworth Learning.[↩](#fnref5){.footnote-back} ::: :::