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Social Determinants of Health and Behavioral Health Challenges

Feature Articles

The behavioral health field is engaged in a movement to expand the conventional medical treatment model of care that emphasizes diagnosis and subsequent treatment to the more comprehensive and inclusive model of population health. Improving “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (Kindig & Stoddard, 2003) is the critical focus of the population health model. The ultimate goal is to redirect the focus on the social determinants of health (SDOH) as the means to reducing health inequities and disparities among different population groups.

 

Research indicates a high correlation among these social inequalities and health disparities (Orsi, Margellos-Anast, & Whitman, 2010); thus, in primary care and public health, the lack of improvement in SDOH confounds our ability to improve the health of a community (Michener, Koo, Castrucci, & Sprague, 2015). What studies have found is that increases in income, educational opportunities, and accessible housing have the largest positive effect on population health (Frieden, 2004, 2010), and that social spending, not health care spending, is significantly associated with improvement in mortality rates (ODPHP, 2018).

 

SDOH focus on the social, environmental, and cultural concerns impacting children, adolescents, and adults who are members of diverse populations within our society (ODPHP, 2018)—Michener and colleagues note that “The contributing factors underlying all chronic illnesses are rooted in complex social, behavioral, and environmental factors, making our health and well-being products not only of the health care we receive but also the places where we live, learn, work, and play. Our zip code can be more important than our genetic code” (2016, p. 4). The current behavioral health system with its focus on acute disorders continues to be inadequate in helping our communities and its members to develop healthy lifestyles. Thus, professionals in varied disciplines (e.g., education, psychology, social work, nursing, and others) are seeing greater evidence that a person’s individual health cannot be separated from an individual’s community health (Koh, Piotrowski, Kumanyika, & Fielding, 2011). Moreover, we believe a lack of attention to these social determinants contributes to the overall “community pathology” and low rates of therapeutic success (Scoles, 2016, p. 21). Educational, therapeutic, healing catalysts can be found in addressing those social determinants that influence many lifestyle choices. Thus, from a community health perspective healing the community heals the individual, understanding that one inherently does not exist without the other. 

 

Environmental and social exposures to factors such as high-crime and drug-infested areas; domestic violence; and lack of access to parks or playgrounds, transportation, quality education, social services, and mental health care create a significant impact on lifestyle choices and trajectories. Therefore, from a behavioral health educational perspective, a college-population-based health focus would best be defined by the advocacy effects to intervene upon and influence these complex social, behavioral, and environmental factors by actively working to engage community organizations, families, schools, and individuals in efforts to create and shape positive and healthy environments in which all members can thrive.

 

Clinical practitioners have been moderately successful in the treatment of individual disorders, but most often are ignorant to and neglectful of the interplay between people’s “pathology” and the community within which they reside. The recognition that people’s health is linked to their community’s overall health is the missing link to consistent and efficient treatment. Without practitioners engaging in a comprehensive evaluation of the concomitant SDOH to which communities and its members are exposed, a long-term successful solution to individuals’ behavioral health challenges can be nearly impossible. Incumbent upon the field of behavioral health is the obligation not only to influence people’s therapeutic choices toward making healthy lifestyle changes, but also to remain active in their communities. Professionals must simultaneously help shape the community perspective of what changes need to occur within and among their existing micro and meso systems to foster more positive and healthy lifestyle factors for all residents residing within.

Each of the five social determinant areas in Figure 1 reflect a critical component or significant issue that makes up an underlying factor in the arena of population health (ODPHP, 2018).

 

The organizing framework is used to establish a set of objectives for the five topic areas. It also identifies existing “Healthy People” objectives in other subject areas that are complementary and highly relevant to social determinants. This organizing framework has been used to determine an initial set of resources and other examples of how a social determinant approach to health is implemented at a state and local level (ODPHP, 2018). 

 

Historically, the lack of a comprehensive vision of health that includes a focus on the influencing SDOH is traced partly to the biomedical movement of the helping professions that sought to replicate the three top elements in the medical model of health care: assessment, diagnosis, and treatment. The cultural and ethnic sensitivity to community processes involved in determining health and pathology in our communities were factors that were lacking in all three of these elements of instituted health care as well as behavior health and social services.

 

The Road to a Population Health Model

 

Certainly behavioral health challenges exist that require diagnosis and medical and psychosocial interventions. Surely, to survive in the behavioral health field, clinicians must know and contribute to the diagnostically driven payment system of health care. The DSM does accomplish its objective of providing an understanding of the complex biopsychosocial concepts of psychiatric diagnosis. 

 

While the etiology of these disorders may be the imprint of a person’s DNA, they are frequently the result of, or compounded by, psychosocial, environmental, and cultural factors. The degree to which these factors play in the overall health of an individual has been a subject of controversy among clinicians. What is known is that deterioration of SDOH in neighborhoods is predictive factor in a person’s chances for recovery from addiction, trauma, and other behavioral health challenges (Michener et al., 2015). If a community is dysfunctional (i.e., lacking necessary supports for economic and social sustainability or its members), the individual’s chances for resilience, health, and wellness decline; therefore, a vulnerable community will just as likely drown its members in poverty, violence, and isolation. When we refer to the individual in this holistic approach to recovery, resilience, health, and wellness, we are not only referring to the person or the family but the community and the neighborhood as a whole (Scoles, 2014, p. 48–64).

 

Throughout most of the history of behavioral health care, community involvement and neighborhood connection were viewed as something that happened near the end of treatment (if at all) depending on adherence and symptom remission and control (Abrahams et al., 2013). Systems did not view the community as capable of promoting people’s health, but as a place to which people might be released when they were “healthier.” People were told to wait until they had achieved abstinence or stability before pursuing any workforce activity or educational studies. The treatment community simply did not view the neighborhood in which clients lived as a possible contributing factor to either the problem or the solution. Finally, the person receiving services along with his or her supporters had very little input into these decisions. The individuals’ immediate eco-community (i.e., family, key allies, spiritual resources) were seldom invited into assessment, planning, or service-delivery processes. Community connections were considered the purview of social workers—and even then were done as referrals rather than intentional connections to these resources (Abrahams et al., 2013).

 

Culture, Ethnicity, and Assessment

 

To help remedy aspects of the aforementioned situation and begin to transform health care delivery, stakeholders in the behavioral health community had to reevaluate the way they assess individuals regarding diagnosis and treatment. The purpose of diagnosis is to identify areas of disruption in a person’s life that have a negative impact on current behavior and lifestyle trajectories. However, the danger in this restrictive perspective is that clinicians will often fail to consider ethnicity, and other cultural and environmental issues. The need for a more environmentally sensitive classification system—one that acknowledges the role that cultural, community, and intergenerational factors play in behavioral health issues and clinical judgments about them—is a topic in need of serious consideration. Historically, this lack of holistic assessment has led to labeling (and stigmatizing) individuals with inappropriate disorders. Certain behaviors and personality styles, when not understood within ethnic or cultural context, could be viewed as deviant or dysfunctional, when in fact, they were culturally congruent. There is increasing pressure for practitioners to become more knowledgeable, comfortable, and skilled in working with individuals from different cultures, ethnic backgrounds, sexual orientations, genders, gender identities, and religious/spiritual orientations. This multidimensional framework provides a more dynamic and realistic therapeutic approach that focuses on assessing the person’s physical, behavioral, emotional, and psychological health within various and diverse environmental and cultural contexts. Moreover, this direct multidimensional practice of direct engagement with clients and community shifts the behavioral health practitioners away from the historical treatment emphasis on psychopathology, disease, and disorder and simultaneously accents resilience, strengths, gifts, and capacities of both of the communities at-large and its residing members (Scoles, 2016, pp. 117–21).

 

The strengths perspective is primarily a philosophy of interpreting information about our body, mind, and community that reinterprets self-defeating behavior, guilt feelings, and dysfunctional relationships. The strengths approach is a more positive framework. The goal of all interactions—and to some extent assessment—is to assist with the identification and augmentation of the individual’s strengths and resources. Many social scientists believe that ethnic and community identity is a significant cultural variable that affects a person’s concept of belonging to other members of a subgroup and defines the individual’s relationship to the dominant culture. These shared influences can influence a person’s willingness to seek help concerning a behavioral health challenge. Additionally, a person’s cultural perspective affects the way in which he or he may describe his or her problems to a professional worker (Olandi, 1995).

 

According to Abrahams and colleagues, “A transformed system also addresses the fact that the health of individuals is affected by the health of the overall community. Provider agencies exist within the community. They are members of the community and therefore have a responsibility to participate in—and assist in improving—the overall health of the community” (2013, p. 113).  

 

A comprehensive behavioral health management approach must embrace a holistic approach that focuses on 

 

  • Eliminating stress in the overall community
  • Being attentive of environmental factors such as divorce, death, and illness
  • Supporting and providing opportunities for better housing, increased employment opportunities, and active family activities

 

Without attention to these SDOH, people will continue to live in a static environment or a neighborhood in decline that becomes a toxic wasteland for individuals, their families and community (White & Sanders, 2008).

 

The behavioral health advocacy movement rose in reaction to the continued stigmatization, medicalization, criminalization, and penalization of behavioral health challenges in the 1980s and 1990s. White and Kurtz (2006) believe that this consumer-driven social movement includes reaffirming the reality of long-term behavioral health recovery; celebrating the legitimacy of multiple pathways of healing; enhancing the variety, availability, and quality of local and regional treatment and community support services; and transforming existing treatment businesses into “recovery-oriented systems of care.”

 

Over fifteen years ago, J. L. Geller indicated that the great challenge for community mental health in the twenty-first century was our continued concerns about the locus of care, and our confusion with the humaneness, effectiveness, and quality of care (Geller, 2000). Geller felt that success would be more reflected in a public health response that addresses issues of individuals who became destitute and marginalized and not in treatment. Geller concludes that even after fifty years of moving “patients” out of state hospitals and putting them somewhere else, behavioral health policymakers and practitioners remain too myopic in their ability to create a system of comprehensive care (Geller, 2000; Cournos & Melle, 2000). The failure of the medical model of community service delivery to consider any evolving advocacy groups in its concept of community care contributed to a standard of care that for years continued to support the underlying dehumanization and stigmatization of people with behavioral health challenges. To bring parity and balance to the healing process population health seeks to build on and complement the classic efforts of the first three paradigms: medical diagnosis, behavioral health counseling, and public health.   

 

Within the field of public health transformation, there are nine guiding principles that support the development of a comprehensive community support network perspective that can impact an individual’s negative environment and exposure to behavioral health challenges which create an atmosphere of change for the person their family and the community (SAMHSA, 2011):

 

1. Healing Should be Person Driven

 

According to SAMHSA, “Self-determination and self-direction are the foundations for recovery as individuals define their own life goals and design their unique paths towards those goals” (2011). 

 

2. Healing Occurs via Many Pathways

 

Healing “. . . is built on the multiple capacities, strengths, talents, coping abilities, resources, and the inherent value of each individual” (SAMHSA, 2011). 

 

3. Healing is Holistic

 

Healing from life’s traumas is a lifelong process that includes one’s mind, body, spirit, and neighborhood. 

 

4. Healing Must be Supported by Peers and Allies 

 

 SAMHSA notes that “Peers encourage and engage other peers and provide each other with a vital sense of belonging, supportive relationships, valued roles, and community. . . . Peer support for families are very important for children with behavioral health problems” (2011).

 

5. Healing Must be Supported through Relationship and Social Networks

 

“Family members, peers, providers, faith groups, community members, and other allies form vital support networks,” and these positive healing processes have led “. . . to a greater sense of belonging, personhood, empowerment, autonomy, social inclusion, and community participation” (SAMHSA, 2011). 

 

6. Healing Must be Culturally Based and Influenced

 

All “services should be culturally grounded, attuned, sensitive, congruent, and competent, as well as personalized to meet each individual’s need,” SAMHSA states (2011).

 

7. Healing Must be Supported by Addressing Trauma

 

The experience of trauma is associated with behavioral health challenges and “Services and supports should be trauma-informed to foster safety (physical and emotional) and trust,” SAMHSA says (2011). 

 

8. Healing Involves the Family and Community Strengths/Responsibilities

 

Individuals have a personal responsibility for their self-care. People must have an opportunity to speak for themselves and families, and significant others have responsibilities to support their loved ones.

 

9. Healing Must be Based on Respect

 

An appreciation and societal acceptance for people affected by behavioral health challenges must include protecting their rights and eliminating discrimination and is crucial in achieving positive outcomes.

 

The nine challenges facing a comprehensive community support network can be enhanced when human service workers, educators, and policy makers embrace a paradigm shift that will facilitate change toward a holistic model of healing that embraces an approach that brings balance to individuals, their families, and their communities. 

 

 
The Philadelphia Story, a Prototype for Building Efficacy

 

This shift to a holistic model of healing is accomplished by creating a transformed system of care for adults with behavioral health challenges. The realization that the old entrenched methods of behavioral health care delivery are not working has provided an impetus for this new movement. The new model is a shift from a professionally driven care approach to a system of care that provides lifetime supports while recognizing the many pathways to health (Lamb, Evans, & White, 2009). Community advocates, behavioral health clinicians, educators, faith-based organizations, and local government agencies are developing blueprints for this model of holistic behavioral health care that address population health. In this uniquely Philadelphia story, professional treatment is one aspect among many that support people in managing their conditions to the greatest extent possible. Transformation to an orientation of resilience in behavioral health service delivery becomes possible by focusing on the central role of individuals, their families, and communities in responding to, managing and overcoming these challenges. This emphasis must be an organizing principle for the entire system (DBHIDS, 2018).

 

This transformation to a new holistic behavioral health approach is framed in a report called “Philadelphia Behavioral Health Services Transformation Practice Guidelines for Recovery and Resilience Oriented Treatment.” This framework is built on ten core values, seven system goals, four domains, and consists of four primary strategies (Abrahams et al., 2013):

 

  1. Building community capacity
  2. Enhancing treatment quality
  3. Changing administrative structures
  4. Mobilizing individuals and their families 

 

The four strategies of transformation specifically refer to healing addictions, trauma, mental health, and psychosocial issues. They capture the inherent foundation of a population health approach to behavioral health and wellness and conceive of such as a system of interaction and reaction operating within a multidimensional framework.  

 

Thus, Philadelphia’s approach to transformation of care responds to some critical elements necessary for providing effective behavioral health services, including evidence-based practices, trauma-informed care, and attention to SDOH. This prototype approach has inherently embraced the construct of a population health reorientation of human services by focusing on long-term prevention, intervention, and individualized primary care, and hopefully will continue to influence and inform many of the intervening social determinants affecting the behavioral health of within the Philadelphia communities as well as those across this nation. 

 

 

References

 

Abrahams, I. A., Ali, O., Davidson, L., Evans, A. C., King, J. K., Poplawski, P., & White, W. L. (2013). Philadelphia Behavioral Health Services transformation: Practice guidelines for recovery- and resilience-oriented treatment. Retrieved from https://dbhids.org/wp-content/uploads/2015/07/practice-guidelines-1-1.pdf 
Cournos, F., & Melle, S. L. (2000). The young adult chronic patient: A look back. Psychiatric Services, 51(8), 996–1000. 
Department of Behavioral Health and Intellectual Disability Services (DBHIDS). (2018). Providing a conceptual framework for recovery transformation. Retrieved from https://dbhids.org/recovery-transformation-papers/conceptual-framework/#
Frieden, T. R. (2004). Asleep at the switch: Local public health and chronic disease. American Journal of Public Health, 94(12), 2059–61.
Frieden, T. R. (‎2010). A framework for public health action: The health impact pyramid. American Journal of Public Health, 100(4), 590–5.
Geller, J. L. (2000). The last half-century of psychiatric services as reflected in psychiatric services. Psychiatric Services, 51(1), 41–67.
Kindig, D., & Stoddard, G. (2003). What is population health? American Journal of Public Health, 93(3), 380–3.
Koh, H. K., Piotrowski, J. J., Kumanyika, S., & Fielding, J. E. (2011). Healthy people: A 2020 vision for the social determinants approach. Health Education & Behavior, 38(6), 551–7.
 
Lamb, R., Evans, A. C., & White, W. L. (2009). The role of partnership in recovery-oriented systems of care: The Philadelphia experience. Retrieved from http://scottishrecoveryconsortium.org/assets/files/2009%20PartnershipPaper.pdf
Michener, J. L., Koo, D., Castrucci, B. C., & Sprague, J. B. (Eds.). (2015). The practical playbook: Public health and primary care together. New York, NY: Oxford University Press.
Office of Disease Prevention and Health Promotion (ODPHP). (2018). Social determinants of health. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
Olandi, M. (1995). Defining cultural competence: An organizing framework. In M. Olandi (Ed.), Cultural competence for evaluators: A guide for alcohol and other drug abuse prevention practitioners working with ethnic/racial communities (pp. 293–9). Rockville, MD: Substance Abuse and Mental Health Services Administration. 
Orsi, J. M., Margellos-Anast, H., & Whitman, S. (2010). Black-white health disparities in the United States and Chicago: A fifteen-year progress analysis. American Journal of Public Health, 100(2), 349–56.
Pols, J. (2005). The politics of mental illness: Myth and power in the work of Thomas S. Szasz (pp. 71–2). (M. De Vries, Trans). Retrieved from http://www.janpols.net/Pols-PDF.pdf (Original work published 1984). 
 
Scoles, P. (2014). Faith, spirituality, and resilience in recovery. Boston, MA: Cengage Learning.
Scoles, P. (2016). Assessment and service planning in recovery. Boston, MA: Cengage Learning.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2017). Recovery and recovery support. Retrieved from https://www.samhsa.gov/recovery
White, W. L., & Kurtz, E. (2006). Recovery: Linking addiction treatment and communities of recovery: A primer for addiction counselors and recovery coaches. Retrieved from http://www.williamwhitepapers.com/pr/2006RecoveryLinkageMonograph.pdf
White, W. L., & Sanders, M. (2008). Recovery management and people of color: Redesigning addiction treatment for historically disempowered communities. Retrieved from http://www.williamwhitepapers.com/pr/2008RecoveryManagement%26CommunitiesofColor.pdf