‘The social determinants of mental health and the importance in a psychologically informed environment’…

07.05.2021: Reflecting back on this week for the PIE blog as the Lead for Psychologically Informed Environments (PIE) at the national youth homeless charity: Centrepoint, and ahead of next week’s Mental Health Awareness week, I came across the image above. I think this illustrates well the social role of various social determinants or influences upon our mental health, and is based on the work of Compton & Shim (2013, 2019). I think this image is important to reflect upon, because it highlights that mental health is not just the responsibility or the result of the individual’s biological or psychological make-up, as perhaps is overly highlighted in a medical model of mental ‘illness’. Rather, it highlights that the social systems in which we live and/or the social experiences we have had, significantly influence our psychological well-being or mental health. I would argue that this is particularly important to consider when working in the homeless sector (and when developing a PIE) because we know that many of our vulnerable or homeless young people have had negative or traumatic social experiences that have had an impact on their later mental health and psychological well-being. This is often actually the rule, rather than the exception. It also highlights that any interventions we undertake with them to #changethestory need to take into account the wider social context.

For example, as shown in the image above, our mental health or psychological well-being is strongly influenced by our social context or norms as well as public policy within the society we live. Perhaps this has been particularly highlighted to many of us personally over the past year, when the social norms and public policy have been to physically distance ourselves from others in order to prevent the transmission of the COVID-19 virus. As I noted almost a year ago in this PIE blog (c.f. https://drhelenmiles.medium.com/physical-not-social-distancing-a-psychologically-informed-approach-to-managing-the-445dacb675d1), the messaging really should have been to keep our ‘physical distance’ because as humans we are innately social animals and to not be connected to others, can increase our risk of social isolation, disconnection, loneliness, and experience of anxiety and depression. For example, a BBC new article this week (c.f. https://www.bbc.co.uk/news/health-56993575) has highlighted this post pandemic increase in depression following a national Office of National Statistics (ONS) study. Of most concern in this article, was the disproportionately high levels of depression in young people aged 16–29 years, particularly amongst females.

However as many leading psychologists have noted (e.g. Dr Lucy Johnstone, Consultant Clinical Psychologist — https://www.theguardian.com/society/2021/apr/16/has-the-pandemic-really-caused-a-mental-health-crisis), it is important that we are not too quick to pathologise the individual, when there is a shared or collective traumatic social experience of ‘lockdown’ within the population. I have also noted that many people, including many of our staff and homeless young people have actually shown amazing levels of resilience in the face of crises, particularly when they have been able to ‘come together’ and support each other. Therefore, any ‘recovery’ of our mental health or psychological well-being post COVID-19 will not just be about providing individual support and resources but will also be about community and social initiatives that ‘build back better’ these critical social influences upon us. These initiatives need to address the social and health inequalities that COVID-19 has highlighted, and we also need safe spaces to connect and support each other, which allow the processing of the past year and any associated challenges or trauma.

Even prior to COVID-19 however, there were perhaps social norms (e.g. stigma, class system, institutional racism, language used around mental health) as well as public policy (e.g. government austerity policies as highlighted by Psychologists Against Austerity — https://repository.uel.ac.uk/download/8c3c9dc582761dee82c7cfc789624b5bd75cbb407a337b5b30558c76a16e9571/257573/Educational%20Psychology%20Research%20and%20Practice%202016%2012%20McGrath.pdf) that created significant risks for our mental well-being. Key support services were cut and/or resources reduced, and there was perhaps even a disproportionate emphasis on individual responsibility for psychological well-being and an increase in division and the blaming of the ‘other’ in our political landscape, all of which created risks for our psychological well-being, particularly if we found ourselves vulnerable in this period. Both pre and even more so post COVID-19, we are seeing that these public policy decisions and social norms resulted in an unfair distribution of opportunity for many people, particularly those most vulnerable such as homeless young people.

As the image above in this blog shows, this unfair distribution of opportunity manifests in many forms within society, all of which have an increasing evidence base that links them to a negative impact on our mental health and psychological well-being. For example, the physical environment such as low quality or inadequate housing options, adverse built environments and air pollution. Moreover, the exposure to and interaction with crime or criminal lifestyles as well as unemployment leading to income inequality and poverty. There may also be the influence of educational inequality due to a lack of quality, access or ability to benefit from education resulting from the other issues noted above, and physical health inequality through a lack of access to healthcare and a healthy diet. Finally, there is also the impact of discrimination due to certain individual characteristics such as age, race, class, sexual orientation, gender or religion. All of these can create the perfect melting pot for a child or young person to mistreated by significant attachment figures or experience adverse childhood experiences, which the evidence shows (e.g. Anda et al, 2010) are highly predictive of later mental health (as well as physical health issues).

Consequently, an individual experiencing these social issues is likely to experience reduced choice and control over their experiences, which can be traumatic in its own right, as well as physical and psychological stresses, all of which increase their risk of poor mental health. Moreover, the social conditions highlighted above in and of themselves create behavioural risks (e.g. risk of being a victim of violence or abuse, or engaging in alcohol and drug use), which of course then can increase their risk of poor mental health. I doubt that anyone working on the ‘frontline’ in our homeless services (or indeed in mental health services) would not recognise this process in action every day. We can easily recognise that the social context in which an individual young person is in can shape and impact upon their mental health or psychological well-being, sometimes despite our best efforts to counter it in the support work that we undertake.

The influence of social context on mental health is so well established now through research and various reviews (e.g. Marmot Review(s) in England; 2010; 2020) that even the World Health Organisation (WHO) have highlighted this specific issue in their 2014 report (c.f. https://apps.who.int/iris/bitstream/handle/10665/112828/9789241506809_eng.pdf;jsessionid=8DC277E5856B0BF35BB3360D251D58C2?sequence=1). This report notes that ‘mental health and many common mental disorders are shaped to a great extent by the social, economic and physical environments in which people live’ and that ‘social inequalities are associated with increased risk of many common mental disorders’ (p.8). Specifically, that a large body of research has now identified that risk factors for many common mental health issues are heavily associated with social inequalities, whereby the greater the inequality the higher the risk. Moreover, it is now clearly identified that certain populations are at a higher risk of mental health issues because of greater exposure and vulnerability to unfavourable social, economic and environmental circumstances, often interrelated with other characteristics such as race and gender (as noted in the image above). This disadvantage starts before birth and sadly continues to accumulate throughout life without significant intervention.

As a consequence, the WHO highlights that it is important that we are ‘taking action to improve the conditions of daily life from before birth, during early childhood, at school age, during family building and working ages, and at older ages providing opportunities both to improve mental health and to reduce the risk of those mental disorders that are associated with social inequalities’ (p.8). What is particularly relevant for the work that we do at Centrepoint, with homeless and vulnerable young people aged 16–25 years, is the value of our ‘early intervention’ wherein we work to change their life course during adolescence and early adulthood; a critical point of intervention. As the WHO also note; ‘whilst comprehensive action across the life course is needed, scientific consensus is considerable that giving every child [or young person] the best possible start will generate the greatest social and mental health benefits’ (p.8). The WHO (2014) concludes that ‘there is a considerable need to raise the priority given to the prevention of mental disorders and to the promotion of mental health through action on the social determinants of health’ (p.9).

Of course, it is not just academic research which has noticed the significance of social influences on our mental health. I hear many stories from staff in our ‘frontline’ services in our monthly reflective practice sessions about the wider system issues, social inequalities and challenges that the homeless young people that they are working with have experienced in the past, and even continue to do so in the present and are at continued risk of in the future. This is where an organisation like Centrepoint can have such a crucial role. As a national charity, we have a unique position of being not just a ‘deliverer of services’ but also a leader in policy and social change. We can use our expertise from the ‘frontline’ to hear and highlight the stories and experiences of some of the most vulnerable young people in the UK (c.f. https://centrepoint.org.uk/youth-homelessness/real-stories/) as well as listening to our staff and hearing the challenges they face ‘on the ground’. This enables us to lobby effectively and from a position of expertise for wider system or social change. Consequently, we can give a voice and power to those who are perhaps traditionally ‘powerless’ in these conversations. We can, as per a psychologically informed environment or PIE, co-produce a different future for those young people at risk of or currently experiencing homelessness.

In addition, Centrepoint has also created through its partnership work (c.f. https://centrepoint.org.uk/what-we-do/partnerships/) the opportunity to expand its voice even further, by working with many other youth homeless charities across the UK that are supporting young people. Last week for example, I have had the pleasure of meeting with Paul Goddard (Operational Manager — Brighton Housing Trust) to discuss their work in implementing a psychologically informed environment approach within their supported accommodation services. It was not only great to connect with a fellow West Sussex raised individual and revisit mentally many of my old haunts (!) but also to hear about all the progress they are making in their PIE delivery and share our similar experiences and challenges. Again, the wider social context of much of the work in the homeless sector we undertake was a theme of our conversations, as well as the importance of improving the physical environment and amplifying our voices in this area by continuing to work together in the future.

Whilst we may work with an individual homeless young person on a day to day basis, as a psychologist I have always been aware of the importance of including the wider societal context in any formulation or understanding of their distress or mental health difficulties, and working with colleagues (e.g. social workers) to ensure that any social issues are addressed (e.g. housing, finances). I have even learnt that sometimes the support around these social issues can have a bigger impact on my client’s mental health than any individual psychological therapy intervention we are attempting to undertake! In addition, even within our organisation, reflecting on our local systems is important and is something that the PIE team has begun to get more involved with over recent weeks. For example, we have been providing consultation on some of our Support and Housing policies and procedures, to ensure that they are not only psychologically informed but also consider the wider social context where possible, including ensuring that they are not inadvertently discriminatory.

Finally, when I have been reflecting on this link between psychological well-being or mental health issues and the social context, I have been thinking again about Centrepoint’s new 5 year strategy, and its emphasis on ‘Prevention’ (c.f. https://editor.centrepoint.org.uk/media/4764/d201-strategy-03.pdf). This ties in with the WHO and research evidence of the role of social inequalities in later mental health issues noted above, as well as homelessness issues in general. Specifically, in order to #endyouthhomelessness it will not just be about intervening to support the individual that needs our services today, but to reflect on how we can prevent a young person being born today from needing our services when they turn 16 year in 2037. In other words, we need to be looking at how we can prevent the social inequalities that create the conditions for homelessness (and any impact on psychological well-being or mental health issues) in the first place. This is a challenge. Centrepoint will not be able to do this on its own and each one of us within the organisation and outside of it has a role to play, starting with being that voice that highlights these social determinants, including the impact of homelessness or insecure housing, which are often ignored or perhaps feel too challenging to address. This conversation is critical, because if we ignore the social context then we ignore a significant influence on psychological well-being and mental health, and consequently we will not actually be creating a true psychologically informed environment…