It is well recognised that social determinants such as the circumstances in which people are born, their access to education and opportunities for employment, where they live, and experiences of discrimination have a significant impact on health and wellbeing (World Health Organisation, 2014). These circumstances are in turn shaped by a wider set of forces involving culture, economics, social policies and politics. As a health profession that bears witness to the outcomes of such social determinants, psychology has a key role to play in addressing such determinants. Indeed, the APS Code of Ethics identifies this responsibility very clearly under General Principle A: Respect for the rights and dignity of people and peoples.
Psychologists engage in conduct which promotes equity and the protection of people’s human rights, legal rights and moral rights.
This ethical principle would sit uncomfortably with the results of a recent overseas study if replicated in Australia, which found that therapists were twice as likely to misdiagnose mental illness when their patients were members of a disadvantaged, compared to an advantaged, group (Nakash & Saguy, 2015).
Most psychologists would be aware that determinants such as early childhood circumstances, gender and culture have a major impact on health outcomes via their effects on cognitive development, educational opportunities and access to appropriate services. Other factors like the built environment, income and housing might not be so obvious. The conclusion they all add up to is that health and wellbeing are influenced by contextual factors beyond the individual traits, attitudes and behaviours that are more familiar to psychologists. We therefore need to broaden our awareness of social factors if we are to effectively promote good mental health.
The bio-psycho-social model is a widely used framework within psychology that considers the role of biological, psychological and social factors and their influence on health and wellbeing. The application of a social determinants of health (SDoH) framework in psychological practice offers a useful means of operationalising the social element of this model, encouraging psychologists to take context into account, to promote equity of access to treatment, and also to work at reducing health inequalities via multi-levelled advocacy and action.
In October 2012, the APS endorsed the World Health Organisation’s social determinants of health approach, acknowledging the social gradient in health and recognising the contribution of social determinants to unequal health outcomes. The APS has joined the social determinants of health Alliance, a coalition of health, social services and public policy organisations, to work with governments to reduce health inequities in Australia. The Alliance has urged Federal, State and Territory Governments to use evidence-informed frameworks to formulate health policy, and to adopt a ‘health in all policies’ approach in areas such as urban planning, housing, education and welfare.
Adopting a social determinants of health approach to psychological practice
An SDoH approach aims to both enhance treatment and address the broader context to promote health and wellbeing. Widening the scope of psychological practice involves a multidisciplinary person-centred approach, assisting clients to access services that address their financial, safety and social needs, and adopting approaches to assessment, treatment formulation and report-writing that value self-determination and empowerment. Beyond the therapy room, initiatives aimed at minimising inequalities, eliminating discrimination and reducing stigma are key to an SDoH approach.
APS SDoH resource
The APS has been developing a practitioner resource to assist psychologists to work in ways that align with an SDoH approach. The resource draws on the Institute for Health Equity report (UCL, 2013), which identifies areas where action is likely to be particularly effective in tackling health inequities. The APS SDoH resource is designed to enable psychologists to reflect on their current practices and prompt them to consider incorporating the following areas.
- Professional practice – improving the scope of existing treatment approaches for better client health and wellbeing
- Collaboration, consultation and engagement – building communication and relationships with external services and bodies
- Broad approach – encouraging more multi-pronged, culturally competent and holistic ways of working and understanding health
- Training and education –increasing knowledge, skills and awareness of broader issues that affect health and wellbeing
- Workforce and employment – cultivating healthy workplaces
- Advocacy – recognising psychologists’ social responsibility to advocate directly or indirectly for a specific issue or policy change they identify as impacting unfairly on clients and communities
- Research – promoting use of participatory, action-orientated research.
The APS SDoH resource has been developed to assist psychologists in their practice, whether using it to inform individual treatment and broader practice approaches, as a peer supervision tool, or as the basis for further professional development. To demonstrate the potential use of the resource, some case examples are provided opposite. Many psychologists will already be incorporating social elements into their case formulations, but less frequently will consider broader ways of addressing these social determinants beyond working with the individual. Hopefully these illustrative examples will encourage psychologists to consider the power of a broader, systemic SDoH approach that will not only assist their clients but also promote the wellbeing of other disadvantaged people and future generations.
The APS SDoH resource can be found on the APS website (www.psychology.org.au/public_interest/social-determinants/).
Members are encouraged to share their feedback, case examples, or any further ideas for embedding an SDoH approach within psychology by contacting firstname.lastname@example.org
Heather Gridley FAPS, Harriet Radermacher MAPS, Emma Sampson MAPS and Suli Tera, APS Student Subscriber
Public Interest team, APS National Office
CASE EXAMPLES APPLYING A SOCIAL DETERMINANTS OF HEALTH FRAMEWORK
Sefina is a 35-year-old Pacific Islander woman who presents with poor coping after the birth of her first child. She is a single parent and is socially isolated from her family, all of whom live interstate.
As well as a mental health assessment, the psychologist takes a social history to contextualise Sefina’s presenting issues and gain an understanding of the multiple social determinants that may be influencing her psychological health and wellbeing, e.g., social connectedness, culture, gender, safety and income. Together they discuss strategies that will assist Sefina to cope with the transition to motherhood and improve her wellbeing, such as expanding her social networks and linking her into a new mothers’ group. After screening reveals several risk factors for relationship violence, the psychologist helps Sefina to develop a plan to ensure her safety and that of her baby.
The psychologist takes initial account of the client’s cultural background via background reading about Pacific Islander perspectives on psychological health, spirituality and wellbeing. However the psychologist refrains from making assumptions about Sefina’s personal cultural beliefs, but works with her to understand how these may influence her help-seeking, therapeutic engagement and service use. Identifying social representations of parenting, particularly prevalent stereotypes about single parenting, also helps avoid a victim-blaming approach in this situation.
Danielle is a 14-year-old girl who presents with panic attacks and disturbed sleep, and reports bullying by peers at school and on social media sites.
Collaboration, consultation and engagement
Beyond ensuring the client is safe and addressing her sleeping problems, the psychologist obtains her informed consent to liaise with the student welfare coordinator and Danielle’s GP to consider ongoing management. The psychologist discusses with Danielle whether and how her family and friends might be recruited as allies in her recovery.
The psychologist engages with the local community by contacting the youth services network and considering ways they could instigate a bullying prevention partnership between local schools, council, media and health professionals.
When Danielle’s symptoms have sufficiently subsided, the psychologist links her to a local peer-led research project that aims to give youth who are victims of bullying a voice. The grassroots group runs peer-led community programs that aim to educate the broader community about the effects of bullying.
Ian is a 60-year-old man living in a regional town who presents with anxiety, alcohol abuse and marital problems. During the initial session the psychologist explores Ian’s social history and learns that he is currently unemployed after recently being made redundant following the closure of a local manufacturing company. He is experiencing financial hardship and is worried about his security approaching retirement age.
Along with assessing and managing the anxiety and alcohol abuse issues, the psychologist’s case formulation takes account of the stresses on and potential support available from Ian’s partner, family and other social networks, and also considers the impact of financial hardship on the client and on the couple's relationship.
Collaboration, consultation and engagement
The psychologist explores non-medical referral options for Ian, including local support groups and personalised employment service providers. The psychologist opens up discussion amongst practice colleagues about the increasing evidence of financial hardship within the community, and its implications for professional practice, including decisions around bulk-billing. The psychologist also liaises with the regional women’s health service for information about possible support options for Ian’s wife.
Given the closure of the manufacturing company and its socioeconomic impact on the small rural community, the psychologist contacts a local support group in the community and explores avenues to promote social support and active community engagement that empower local residents and workers to participate in collective action addressing rising local unemployment and attracting new industries to the area. Together they consider approaching their local member of parliament to raise this issue.
Training and education
The local Mental Health Professionals Network (MHPN) group begins discussing the community mental health impacts of the manufacturing plant closure, especially for older male workers. The practice director decides to look into professional development opportunities that may assist psychologists and other health professionals to work with this client group.