Clinical Approaches to Address Social Determinants of Mental Health

This article defines social determinants of mental health (SDMH), and explores how clinicians can assess and address adverse SDMH in clinical practice.

Related articles: Rethinking Wellness: A Holistic Perspective on Health, Understanding Adverse Childhood Experiences (ACEs), Is Your Client Mentally Ill or Just Having a Tough Time?

Related discussion: Social determinants of mental health: Expanding our lens.

Introduction

Mental health is deeply intertwined with the environment in which individuals live, work, and grow. Beyond biological and psychological factors, social determinants of mental health (SDMH) play a pivotal role in shaping wellbeing. These determinants include socioeconomic status, education, housing, access to healthcare, and social support networks, among others. Adverse social determinants can significantly contribute to the development and exacerbation of mental health issues, creating barriers to recovery and resilience.

For mental health professionals, understanding and addressing these social determinants is essential. By integrating assessment, clinical strategies, and advocacy, therapists can mitigate the impact of adverse conditions and empower their clients toward better mental health outcomes. This article explores what SDMH are, how clinicians can assess them, and actionable strategies to address these challenges in practice.

What are social determinants of mental health?

Social determinants of mental health refer to the conditions in which people are born, grow, live, work, and age. These factors influence an individual’s mental health risk and protective factors, often interacting with biological and psychological vulnerabilities to shape overall wellbeing. Key social determinants include:

• Economic stability: Poverty, unemployment, and financial insecurity.
• Education: Lack of access to quality education and early childhood development opportunities.
• Social and community context: Discrimination, lack of social support, and community disengagement.
• Healthcare access and quality: Reduced availability of mental health services and insurance coverage.
• Neighbourhood/suburb and environment: Lack of access to safe housing and reliable transportation and exposure to violence or environmental hazards.

Research has demonstrated that individuals experiencing adverse SDMH, such as poverty or social isolation, are at heightened risk for anxiety, depression, and stress-related disorders (World Health Organization [WHO], 2020). Conversely, protective factors like stable housing and supportive relationships can foster resilience.

Assessing adverse social determinants of mental health

Identifying adverse social determinants is a critical first step for mental health professionals. Comprehensive assessment tools can help clinicians gather information about clients’ social environments and identify areas requiring intervention.

Commonly used assessment tools

Before we look at some commonly used assessment tools, an important reminder: when using assessment tools, therapists should remember that these are starting points for understanding a client’s broader social context. Each tool provides a structured approach to uncovering challenges but must be complemented by open dialogue and professional judgment. For example, while a tool may identify food insecurity, it is through empathetic inquiry that a therapist might uncover how this issue impacts a client’s self-esteem or family dynamics.

Combining structured tools with personalised discussions ensures a more holistic understanding, enabling opportunities for rapport-building and tailored interventions that address both immediate needs and long-term wellbeing:

• Social Determinants of Health Screening Tool: Often used in primary care settings, this tool assesses domains such as housing, employment, food security, and transportation. Adaptations for mental health settings are available.
• Structural Vulnerability Assessment Tool (SVAT): This tool evaluates structural and systemic barriers impacting clients’ mental health, such as discrimination, legal issues, or unsafe neighbourhoods.
• Holistic Psychosocial Assessment: Integrates social determinants into a broader mental health evaluation, examining factors like support systems, cultural influences, and economic challenges.
• The PHQ-SADS (Patient Health Questionnaire): While primarily a clinical screening tool for mood and anxiety disorders, it can include a psychosocial module for exploring contextual stressors.
• Community Assessment Tools: Some clinicians use geographic or community-specific tools, which evaluate access to local resources like healthcare facilities and support networks.

Practical tips for clinical assessment

Effective assessments often go beyond gathering information; they help clients feel understood and validated in the face of systemic challenges. For instance, exploring how financial stress or housing instability influences a client’s mental health can not only guide therapeutic interventions but also foster a sense of empowerment by collaboratively identifying actionable steps to address these issues. By combining evidence-based tools with compassionate dialogue, therapists can ensure that assessments become a foundation for meaningful and transformative care. Here are some practical tips to consider during sessions:

• Open-ended questions: Ask clients about their daily challenges, such as managing bills or accessing reliable transportation. Questions like, “What are some of the biggest obstacles you face in your daily life?” or “How do you feel your living situation affects your stress levels?” can provide deeper insight.
• Cultural sensitivity: Tailor assessments to the client’s cultural background, recognising unique stressors and protective factors. For example, understanding community-specific challenges like immigration status or cultural stigma toward mental health can shape how questions are framed.
• Collaborative conversations: Engage clients in identifying priorities for intervention, fostering a sense of agency. For instance, a therapist might ask, “If we could focus on improving one aspect of your current situation, what would it be?”
• Empowering referrals: Provide clients with practical resources alongside assessment. For instance, if a client struggles with food insecurity, connecting them to local food banks or community kitchens as part of the assessment process can build trust and offer immediate support.
• Structured tools with follow-up: Use validated tools, such as the Social Determinants of Health Screening Tool, and follow up with detailed conversations. For example, if a client’s responses indicate housing instability, the therapist can explore the emotional impact and discuss possible solutions, such as housing assistance programs.

Empowering interventions and therapeutic approaches

Therapeutic interventions aimed at addressing adverse social determinants of mental health must go beyond symptom management to actively empower clients. This involves fostering resilience, building confidence, and equipping clients with the skills needed to navigate systemic barriers. Interventions should be rooted in empathy and adaptability, recognising the unique challenges each client faces.

By integrating evidence-based approaches such as CBT, narrative therapy, and strengths-based frameworks, therapists can address both the emotional and structural dimensions of their clients’ struggles. The ultimate goal is not just to mitigate the impact of adverse determinants but to help clients thrive despite these challenges. The inclusion of practical tools, collaborative efforts, and advocacy within therapy strengthens its effectiveness, enabling therapists to address the broader context of mental health issues and advocate for systemic change.

Narrative therapy

Narrative therapy helps clients reframe their experiences by identifying and challenging dominant social narratives that may perpetuate feelings of helplessness. For example, a client facing systemic discrimination might work with a therapist to construct a personal narrative that emphasises resilience and agency.

A case example: A client experiencing workplace discrimination related to their ethnicity might feel powerless. Through narrative therapy, the therapist helps them identify moments of strength and advocate for fair treatment, transforming the narrative from victimhood to empowerment.

Motivational interviewing (MI)

Motivational interviewing is particularly effective for clients facing socioeconomic challenges who may feel stuck or ambivalent about change. The collaborative, goal-oriented approach helps clients explore their values and motivations.

A case example: A therapist working with a client who is unemployed and struggling with substance abuse might use MI to explore the client’s desire for stability and self-improvement, building confidence to take actionable steps.

Empowerment-based cognitive behavioural therapy (CBT)

CBT can address the psychological impact of adverse SDMH while incorporating empowerment techniques. Therapists can help clients identify and challenge beliefs that stem from systemic oppression or poverty.

A case example: A client living in poverty may develop a belief that “I’m not capable of success.” The therapist works to reframe this belief by highlighting past achievements and setting small, achievable goals, fostering a sense of control and accomplishment.

Strengths-based interventions

Adopting a strengths-based approach entails identifying and leveraging clients’ inherent strengths to overcome challenges. For example, a client with a strong sense of community might be encouraged to seek support from local networks.

A case example: A single parent struggling with housing insecurity might be encouraged to lean on supportive family members or friends while working with the therapist to develop a long-term housing plan.

Ecological systems theory in practice

Therapists using this framework consider the multiple layers of influence on a client’s mental health, from individual factors to societal systems. Interventions might include advocacy at the systemic level while addressing individual coping strategies in therapy.

A case example: A therapist working with a child experiencing school bullying might address the child’s self-esteem in therapy, collaborate with school staff to improve policies, and connect the family with community support groups.

Strategies to address adverse social determinants

Once adverse social determinants of mental health are identified, therapists can employ a multi-faceted approach to mitigate their effects. Strategies include targeted clinical interventions, collaborative care models, and advocacy efforts.

Clinical strategies

Clinical strategies form the backbone of addressing adverse SDMH, focusing on mitigating the immediate psychological effects while promoting long-term resilience. These interventions should be personalised, evidence-based, and attuned to the client’s unique experiences. By integrating techniques such as trauma-informed care, psychoeducation, and solution-focused approaches, therapists can provide support that not only addresses mental health symptoms but also empowers clients to navigate systemic challenges.

Therapists can also help clients develop skills for stress management and self-advocacy, fostering a greater sense of control in the face of adversity.

• Trauma-informed care: Adverse social determinants often intersect with trauma, such as domestic violence or systemic discrimination. Trauma-informed care ensures that therapists recognise the prevalence of trauma, avoid re-traumatisation by creating a safe therapeutic environment, and empower clients through choice and collaboration.
• Psychoeducation: Educating clients about the connection between social determinants and mental health can help normalise their experiences and reduce self-blame. For instance, a therapist working with a client experiencing unemployment-related stress might explain how financial insecurity impacts anxiety levels.
• Cognitive-behavioural interventions: Cognitive-behavioural techniques can address the psychological effects of adverse SDMH, such as low self-esteem or catastrophic thinking. For example, clients struggling with housing instability might benefit from reframing thoughts about control and resilience.
• Solution-focused therapy: This approach can empower clients to identify actionable steps toward addressing specific challenges. For instance, a client worried about food insecurity might collaborate with the therapist to access community food programs.

Collaborative and systems-based strategies

Collaboration is essential for addressing the multifaceted impact of adverse SDMH. By working alongside other professionals such as social workers, case managers, and community organisations, therapists can ensure clients receive comprehensive care. These partnerships help bridge gaps in services, providing clients with access to resources like housing support, financial aid, and legal assistance.

Therapists can also advocate within systems to improve policies and accessibility, making mental health care more inclusive and effective for those facing systemic barriers.

• Interdisciplinary care: Partnering with social workers, case managers, and community health workers allows therapists to provide holistic support. For example, a case manager might help a client navigate housing applications, or a social worker could assist in connecting clients with financial aid programs.

• Referral networks: Building a network of trusted community organisations ensures that clients can access necessary resources. Therapists can collaborate with agencies specialising in areas like domestic violence support, employment counselling, and addiction recovery services.

• Advocacy within healthcare systems: Therapists can work within their organisations to advocate for policies that reduce systemic barriers, such as implementing telehealth services for rural clients or offering sliding-scale payment options.

Advocacy and social action

Advocacy and social action extend the therapist’s role beyond the therapy room, aiming to create systemic changes that benefit clients and their communities. This involves engaging in initiatives that address structural inequities, such as housing shortages or discrimination, and empowering clients to participate in these efforts.

By combining professional expertise with community involvement, therapists can influence policies and foster environments that support mental health equity. Advocacy not only benefits individual clients but also contributes to broader societal well-being.

• Community engagement: Therapists can participate in local initiatives aimed at improving social conditions, such as affordable housing projects or anti-discrimination campaigns.

• Policy advocacy: Clinicians can use their expertise to inform policymakers about the mental health impacts of adverse social determinants. For example: Submitting testimony for legislation promoting mental health parity, and joining professional associations that advocate for systemic change.

• Empowering clients: Therapists can encourage clients to engage in self-advocacy by teaching skills for navigating systems (such as writing letters to landlords or accessing legal aid) and supporting participation in peer-led community groups or social movements.

An example of integrating these strategies to support a client is of a therapist working with a single mother who is facing eviction. The therapist may simultaneously: 1) Address the immediate psychological impact using stress management techniques; 2) collaborate with a housing agency to secure emergency accommodation; 3) advocate for local policy changes to expand affordable housing programs.

Conclusion

Adverse social determinants of mental health present significant challenges for individuals and communities. However, mental health professionals are uniquely positioned to address these barriers through a combination of clinical care, interdisciplinary collaboration, and systemic advocacy. By recognising the broader context of mental health issues and integrating targeted strategies into practice, therapists can foster resilience and equity in their clients’ lives.

Therapists must also remain attuned to their own professional growth, seeking continuing education on social determinants and engaging in reflective practice. Ultimately, addressing SDMH is not only a clinical imperative but also an ethical responsibility to promote mental well-being for all.

Key takeaways

• Social determinants of mental health include economic stability, education, social support, healthcare access, and neighbourhood conditions.
• Adverse SDMH significantly contribute to mental health challenges, necessitating comprehensive assessment tools and culturally sensitive practices.
• Therapists can address SDMH through trauma-informed care, psychoeducation, cognitive-behavioural interventions, and solution-focused therapy.
• Interdisciplinary collaboration, referral networks, and advocacy are essential strategies for mitigating systemic barriers.
• Empowering clients to engage in self-advocacy and community participation fosters resilience and autonomy.

References

• World Health Organization. (2020). Social determinants of mental health. Retrieved from https://www.who.int/publications/i/item/9789241506809
• Marmot, M., & Bell, R. (2019). Social determinants and non-communicable diseases: Time for integrated action. BMJ, 364, l251. https://doi.org/10.1136/bmj.l251
• Pender, V. B. (2021). Addressing Social Determinants of Mental Health. Psychiatric News, 56(7). https://doi.org/10.1176/appi.pn.2021.7.42
• Patel, V., Saxena, S., Lund, C., & Thornicroft, G. (2018). The Lancet Commission on global mental health and sustainable development. The Lancet, 392(10157), 1553-1598. https://doi.org/10.1016/S0140-6736(18)31612-X
• National Academies of Sciences, Engineering, and Medicine. (2019). Integrating social care into the delivery of health care: Moving upstream to improve the nation’s health. Washington, DC: National Academies Press.
• Adler, N. E., & Stewart, J. (2020). Health disparities across the lifespan: Meaning, methods, and mechanisms. Annual Review of Public Health, 41, 17-41. https://doi.org/10.1146/annurev-publhealth-040119-094033