The ‘missing link’ in case conceptualisation and treatment

As practitioners, psychologists operating at the coalface between societal conditions and individual wellbeing face a number of challenges. One challenge is to remain abreast not only of developments within our areas of expertise, but within the broader paradigms that inform our practice. A related challenge is to respond to those developments in ways that are compatible with our existing knowledge base and skill sets. How, for instance, is the World Health Organization’s (WHO) advice to address “social, economic, environmental, and political determinants of the distribution of mental disorders”(WHO, 2014, p.12) to be incorporated into practitioners’ existing frameworks for delivering care?

Steven Mayers and Emma Agnew argue cogently in this issue of InPsych for a number of approaches, including drawing upon principles of community psychology (see previous article). Community psychologists work to support behaviour change with individuals, but fundamental to their approach is also working at a broader level to reduce inequality and build systems and structures that enable and empower communities. This work recognises the social determinants of health that lie in disadvantage and exclusion (Gridley & Sampson, 2010). This important direction is also advocated by the WHO and the United Nations (UN). In 2017 the United Nations Special Rapporteur on the right to health said that, “we need little short of a revolution in mental health care... We need bold political commitments, urgent policy responses and immediate remedial action” (UN Human Rights Office of the High Commissioner, 2017).

However, given the calls to revolutionise our approach, how do practitioners and clinicians help the individuals grappling with society as it is right now, in their therapy rooms day-to-day? How do psychologists respond to the advice of bodies such as the WHO and UN trained as we are in medical models revolving around individual diagnosis and treatment? How can we integrate insights from community psychology into the knowledge and skills that we already possess? Is “everything [we] thought [we] knew about depression wrong?” as an article in the Guardian citing the work of Sir Michael Marmot, Chair of the Commission on Social Determinants of Health (SDOH) recently suggested (Hari, 2018).

Even from within an individualised, less community-oriented framework, meta-analytic research by John Norcross and colleagues (Norcross & Wampold, 2018) has challenged scientist-practitioners to broaden their horizons when thinking about clients and their care. According to the work of Norcross and others, the specific therapeutic interventions or modalities employed by practitioners account for only a small percentage, from 2 to 12 percent on average, of therapeutic gain (Beutler et al., 2003; Norcross & Lambert, 2006). Even matching intervention to diagnosis (Norcross, 2011) yields similar results (with a few exceptions such as implementing exposure therapies for anxiety disorders). Nevertheless, most practitioner training and professional development focuses on exhaustively refining and extending psychologists’ repertoire of specific interventions, rather than broadening our understanding of how else to help our clients. Accordingly, Norcross and colleagues argue that psychological training, research and practice must look beyond matching treatment intervention to clients’ presenting problems, and consider a wider range of factors, in order to better tailor psychotherapy to individual clients.

The premise of Norcross and others is essentially that while the evidence base in psychology has historically been good at equipping psychologists to assist clients who approximate the mean in randomised controlled trials (RCTs), evidence-based responding to individual variations around that mean in practice has been neglected (Norcross & Wampold, 2018). Particularly absent from much of the controlled research and clinical training has been adapting psychotherapy to the person of the patient, beyond his or her disorder (Norcross & Wampold, p.3).

Indeed, flexible responsivity to the unique needs of individuals holds a central role in the very definition of evidence-based practice. The American Psychological Association (APA), for instance, defines evidence-based practice as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences” (APA, 2006, p.273). Given this, and given the growing evidence concerning the importance of social determinants of mental health, SDOH appears to be a neglected consideration in tailoring our interventions to clients’ individual circumstances and needs.

In broadening the focus to include SDOH, another challenge facing many practitioners and clinicians is that recognising and addressing societal conditions in therapy, such as structural racism, economic inequality or workplace relations, may feel too ‘political’ for a scientist-practitioner. The ‘activist-practitioner’ model outlined by Mayers and Agnew in the previous article is consistent with the WHO and UN’s recommendations, but may not sit comfortably with some psychologists’ alignment to a neutral, empirical, apolitical stance. However, given the growing evidence regarding social, economic and political drivers of health and illness, failing to consider such influences is to turn a blind eye to research and evidence. Which, arguably, is the more political, less neutral and empirical stance.

In short, simply following the evidence leads to a focus on SDOH. Research in the United States, for instance, has found that an annual $45 per capita increase in public assistance funding (education and training assistance, welfare spending, health and family benefits) is associated with a 10 percent reduction in suicide rates (Flavin & Radcliff, 2009). Similarly, political scientist Patrick Flavin and his colleagues have found that a nation’s subjective wellbeing increases with the degree of labour unionisation (Flavin, Pacek & Radcilffe, 2010). Flavin and colleagues have also found that, across OECD nations, ease of access to welfare and labour market regulation shows a larger relationship to wellbeing than being married or employed, concluding that the psychological impact of a government’s balance between the market and the state is “profound” (Flavin, Pacek & Radcilffe, 2014).

Making room for such findings in therapeutic practice brings us back to the question of how our more individually focused paradigms can accommodate social determinants.

Socially aware case conceptualisation

As the previous article also notes, an existing cornerstone of sensitive and responsive psychological care, which facilitates inclusion of SDOH, is the case formulation. Being a collection of working hypotheses concerning the nature, causes and moderating influences on a client’s presenting problems, relevant social determinants can be readily hypothesised and integrated into case conceptualisations.

Although specific approaches to case formulations vary, conceptualisations typically entail hypotheses in the following group of categories: presenting problem (the symptoms, behaviours, issues or experiences for which a client seeks assistance); predisposing factors (factors that confer vulnerability to the presenting problem like genetic inheritance, personality traits, or previous experiences such as trauma or developmental history); precipitating factors (factors that catalyse or exacerbate the presenting problems such as stressors, illness, trauma or other adversity); maintaining factors (factors that perpetuate the presenting problem such as counterproductive coping, isolation, contingencies in the person’s environment, chronic stressors, ambivalence regarding change and so on); and protective factors (factors that ameliorate the person’s presenting problems for instance social support, internal resources like flexibility and humour, or motivation for change).

Should social determinants be considered as potential factors within these categories, they, like any other factor, would be expected to impact different individuals differently, just as trauma does, for example. Part of the skill of case conceptualisation is collaborating with a client, in a process of mutual exploration and hypothesis-testing, to form ever-closer approximations of a shared understanding of what drives that person’s suffering and wellness. During the process of collaboration, hypotheses regarding social determinants can be considered and explored, along with other hypotheses.

Incorporating social determinants in case formulations in this way helps to avoid the trap of medicalising social problems such as discrimination, exploitation and inequity. Such influences in people’s lives are often subtle, particularly if culturally normalised, and can be easily missed. However, for some clients they may be the ‘missing link’ in case conceptualisation and treatment. Such an approach to formulation, moreover, is consistent with psychologists’ ethical responsibility to uphold justice (APS Code of Ethics).

Treatment implications

Including social determinants in case formulations paves the way to address those determinants in therapy and treatment, as any other factor might be addressed. Across therapeutic modalities, existing interventions lend themselves in a range of ways to incorporating SDOH.

Perhaps the most obvious entry point is to acknowledge, name, explore, normalise and validate the impact of social determinants on a client’s personal experience. Drawing links between a client’s relationship to the social determinants in their life and other psychological patterns, such as self-castigation and self-blame for instance, can be another fruitful path.

Behaviourally, identifying and re-working self-defeating patterns, such as self-subordination, is an additional possibility. A woman or member of a racial minority group, for instance, who makes sexist or racist remarks at their own expense as a coping strategy, with adverse impacts on self-concept, could be helped to critically examine the broader societal origins of their self-disparagement, along with alternative ways of relating to themselves and others.

An additional behavioural pathway, if congruent with a client’s values and goals, is engaging in initiatives to address the causes of social injustices and inequities. For example, one approach to helping children cope with climate change is to support their engagement in ‘active citizenship’, such as volunteer work, attending marches and protests, or writing letters to politicians and CEOs (Burke, Sanson & Van Hoorn, 2018).

Taking action on social determinants in this way can be conceptualised in terms of a range of existing therapeutic concepts and modalities, such as the behavioural pattern breaking of schema therapy, behavioural activation of cognitive behaviour therapy, or acting in accordance with one’s values as in Acceptance and Commitment Therapy. In terms of therapeutic mechanisms, active citizenship holds the potential to enhance self-efficacy, confer the benefits of altruism and/or goal-directed action, or to increase a person’s sense of belonging and purpose.

Cognitively, self-talk that echoes socially-determined messages can be explored. For example, someone whose career path is adversely affected by automation or austerity may have internalised the meritocratic assumptions of free-market ideology: namely that ‘the market’ rewards those who are worthy and discards those who are not. Such self-talk can be examined and socratically explored like any other cognition or belief, responded to mindfully, or incorporated into compassion-focused work, as a few examples.

In short, psychologists who are trained in largely medical, individual and/or relational models of client care need not wait for a revolution in those models to respond to paradigm shifts and incorporate SDOH in clinical practice. We have the knowledge and tools to begin responding now.

The first author can be contacted at [email protected]