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Causes and Treatments for Disorders

• Causes of mental disorders are complex and vary.
• Appropriate treatment is linked to the underlying cause.
• Several perspectives exist:
  • Biological/biomedical
  • Psychoanalytical/psychoanalysis
  • Humanistic/person-centred
  • Cognitive
  • Behavioural

Biological Perspective

• Views psychological disorders as caused by:
  • Genetic factors
  • Poor neurotransmitter activity
  • Brain abnormalities (tumors, prenatal damage)
  • Infection, diseases (psychosis caused by bacteria)
  • Toxins, substances (mood and anxiety from heavy metals)

Genetic Factors

• Research indicates genetic links between disorders (ASD, ADHD, Bipolar, Major Depressive Disorder, Schizophrenia).
• Epigenetics may explain differences in disorders among family members.

Epigenetics

• Genetic predisposition + environmental factors in gene expression.
• Example: Gene for schizophrenia activated by drug use.
• Nature (genetics):
  • Genes exist but are not activated until gene expression changes (DNA methylation or histone modification).
• Psychological Disorders with Epigenetic links:
  * Schizophrenia
  * Bipolar
  * Depression
• Nurture (environment):
  • Environmental factors causing epigenetic changes:
    • Stress and Trauma
    • Exposure to drugs or chemicals
    • Diet and nutrition

Poor Neurotransmitter Activity

• Disorders linked to communication problems between neurons (neurotransmission).

Neurotransmission

• Studies link low serotonin to depression.
• Reproductive and stress hormones can cause mental health symptoms.
• Cortisol (stress hormone) can cause anxiety and depression.

Biological Perspectives - Treatments

• Major categories used to treat (example):
  • Mood stabilizers (Bipolar - Lithium)
  • Antidepressants (Depression - SSRIs)
  • Anti-anxiety (Anxiety - Benzodiazepines)
  • Antipsychotics (Schizophrenia - Atypical neuroleptics)
  • Stimulants (ADHD - Ritalin)

Biological Treatments - Schizophrenia

• Neurotransmitter involved: Dopamine
• Link to Schizophrenia: High dopamine levels in certain brain areas may trigger schizophrenia symptoms.
• Two main types of antipsychotics:
  • Typical: Block dopamine receptors (Haloperidol)
  • Atypical: Block other receptors, including serotonin, noradrenaline, and glutamate (Risperdal, Olanzapine)
• Which is better?
  • Typical: No impact on negative symptoms, high rate of side effects.
  • Atypical: Fewer side effects, improve negative and positive symptoms.

Biological Perspective - Treatments - Depression

• Neurotransmitter involved: Serotonin
• Link to depression: Low serotonin is linked to depression.
• Medications Available: SSRIs and SNRIs are most common.
• How they work:
  • SSRI’s work by blocking the reuptake of Serotonin in the synaptic gap, allowing serotonin to remain in the gap and build up between neurons so messages can be sent correctly.
• $SSRIs block serotonin reuptake, increasing serotonin levels in the synaptic gap$
• Do they work?
  • The effectiveness continues to be debated.

Case Study: Mould and the Onset of Mental Decline

• Mould and Mental Health Case Study.

Cognitive Perspective

• Developed by Aaron Beck.
• Beck noticed that people were often involved in similar, automatic, negative thinking patterns.
• Thoughts are typically self-critical and can devolve into cognitive distortions.

Negative Self-Talk

• Negative self-talk feeds mental illnesses like depression and anxiety.

• Occurs through neural pathway creation (neuroplasticity).

• Pathways strengthen through rumination (replaying the thought).

• Cognitive approach: Use mechanisms that create negative self-talk to change it by identifying, challenging, and substituting thought patterns.

Cognitive Treatment

Involves identifying, challenging and substituting thought patterns

1. Catch the thought:

   • Start to take notice when you are having intrusive thoughts, pay conscious attention to them
   • For example: “I didn’t get the job, I’m a total failure, I’ll never be good enough for anything”.

2. Check its accuracy:

   • Assess the thought for how useful and realistic it is
   • For example: “I’m disappointed, but it doesn’t mean I’m a total failure”.

3. Change the thought:

   • Substitute the negative thought for one that is more helpful and has a more positive outlook.
   • For example: “I didn’t get this job, but there are other opportunities and better jobs for me”.

Behavioural Perspective

• Mental disorders can result from conditioning.
  • Classical Conditioning - PTSD
    • A car backfires (sounds like a gun) causing a person to re-live a traumatic memory.
  • Operant conditioning – OCD
    • In OCD, the performance of a compulsive behaviour acts as a “reward” by removing anxiety (negative reinforcement). However this is only short-lived.

Behavioural Treatment

• Uses the principles of conditioning to change disruptive behaviours and improve human functioning.
• Useful for fears, anxiety and personality issues.
• Examples include:
  • Systematic desensitisation: Client gradually exposed to a feared object or situation.
  • Aversion therapy: Trying to change a behaviour by associating it with something negative.

Cognitive Behavioural Therapies

• A combination of cognitive and behavioural therapy techniques.
• Changes maladaptive behaviour patterns along with the distorted thought patterns that underlie them.
• Depressive disorders:
  • changing negative thought patterns whilst introducing helpful behaviour patterns, e.g. going for a walk everyday
• Anxiety disorders:
  • visualisation techniques or role playing anxiety provoking scenarios

How it works:

• Changes maladaptive behavior patterns along with the distorted thought patterns that underlie them.
• What does the client state is the problem?
• What did the therapist suggest?
• What was the client’s response?
• What needs to happen next?

Criticisms of CBT -

• Complete the final question on the worksheet “Is CBT an appropriate treatment for mental illness?”

Psychoanalytic Perspective

• Freud was inspired by Charcot, who used hypnosis to treat hysteria.

• Freud worked with Breuer, whose method involved patients speaking freely.

• Breuer’s case study, “Anna O,” began “talk therapy”.

• Breuer diagnosed hysteria; Freud explained Anna O’s symptoms (hallucinations, paralysis, speech problems) as repressed memories and traumas.

• Her case played a key role in the birth of psychoanalysis.

• Freud believed mental illness originates in the unconscious since much of our mental life operates outside conscious awareness.

• Unconscious forces can cause mental health problems:

  • Childhood experiences (conflict and fixation)
  • Repressed trauma
  • Overdeveloped id or superego
  • Failure of defense mechanisms to protect the ego

• Manifestations result in anxiety, depression, and personality problems.

• "Psychoanalysis Key Term Recap" Complete the activity on the Google Classroom.

• Treatment involves bringing unconscious issues into consciousness.

• Psychoanalytic therapy creates conditions for patients to bring conflicts into the conscious mind, where they can be addressed.

• Understanding the origin of symptoms allows patients to gain control.

Therapy

• Therapy involves ways to access the unconscious mind, including:
  • Free Association
  • Dream Analysis
  • Freudian Slip

How it has changed?

• Of less relevance today - unconscious fantasy, sexual desires (libido, penis envy, Oedipal complex), and dreams

• However - deep, individualized talk therapy still remains a relevant therapeutic technique, aiming to uncover ideas and memories buried in the unconscious mind that are causing psychological distress.

• Psychoanalysis (Psychoanalytic Approach)

How it works in practice:

• What did the therapist do?
• What did the patient do?
• What did the patient reveal?
• How could this be interpreted?

FINAL QUESTION

• Should psychoanalysis still be practiced by mental health professionals? Why/why not?

Humanistic Perspective

• Carl Rogers = one of the founders of humanism and the creator of client-centred (or person centred) therapy.
• Mental health issues stem from poor self concept as a result of:
  • Incongruence between real and ideal self
  • lack of unconditional positive regard
• The individual wants to self-actualise and be fully-functioning, but doesn’t know how to be.
• Role of the therapist to guide individual to find the answers for themselves.
• Treatment:
  • People receiving therapy are called clients, not patients (to create a more equal relationship
  • The therapist will use a number of techniques to guide the individual to find solutions for themselves and give them a sense of ownership and control 79.
  • Avoids advice or suggestion – not the role of the therapist 80.
  • Reflecting – repeating back what is being said, e.g. “I hear you saying… ” 81. This allows the client to hear back what they have said and process the information both internally and externally.
  • The therapist will possess the character traits that allow them to best listen and respond to their clients
    • Being genuine – the therapist is just as human as the client
    • Empathising – validating the feelings of the client, e.g. “That must have been really difficult for you” 82.
    • Providing unconditional positive regard – using a tone of voice and phrasing that is never judgemental, always accepting.

Criticisms:

• Too vague - some clients can’t operate without any direction
• Relies on active participation - not useful for those that lack motivation
• Ineffective for clients with severe mental illness - such as disorders alter perceptions of reality
• Doesn’t necessarily offer practical strategies
• Rests on the assumption that people are inherently good and want to self-actualise

How it works in practice:

• What did the therapist do?
• What did the client do?
• What was the outcome?

COMPARE AND CONTRAST THE TWO APPROACHES (PSYCHOANALYSIS AND CLIENT-CENTRED)

• Complete the final activity on the worksheet - Compare and contrast the two approaches

Social and Environmental Factors

• The “Social” part of the Biopsychosocial model refers to external factors such as:
  • Specific environmental triggers
  • Support networks
    • Informal - family & friends
    • Formal or informal support groups
  • Cultural context and social norms

Specific Environmental Triggers

• Environmental influences may play a role in the demonstration of mental health symptoms. For example:
  • Trauma - very common - something reminds the individual of the trauma
  • Sensory - over or under stimulation in an environment can produce symptoms
  • Maladaptive behaviours - drug use and addiction
• Treatment will consider management strategies for coping with environmental triggers
  • Strategies such as CBT for triggers
  • adding or removing stimulation
  • treatments that also address self-medication issues

Support Networks

• Informal Networks - Family and friends. They have the most interaction with the individual and their influence is powerful.

  • Pros: Can offer ongoing encouragement and understanding; Have a good knowledge of the individual and their specific needs
  • Cons: They may not be understanding or helpful; Can make the situation worse

• Online Networks (Informal) - Social Media Advice forums, Group Chats etc.

  • Pros: Helpful if individual does not have support in real life; Person can feel validated hearing about experiences similar to theirs
  • Cons: can be an “echo chamber” where unhelpful thoughts and ideas are promoted and encouraged; Open to advice that lacks evidence

• Online Networks (Formal) - organisations such as Beyond Blue, Lifeline, Headspace, etc.

  • Offer non-judgemental, practical support.
    • Pros - advice that is grounded in evidence; Access is available to anyone at anytime
    • Cons - Not specific to the individual

Cultural Context Factors

• Wider cultural views about mental health have a large influence. Stigma in relation to mental health has been, and continues to be, an ongoing and widespread problem.
• Stigma: negative stereotypes associated with a trait that sets a person apart, such as a mental health diagnosis.
• Stigma often leads to discrimination and can prevent someone from being honest about seeking or sharing a diagnosis.
• Although some disorders experience less stigma than in the past (such as anxiety and depression), it remains pervasive, particularly in relation to psychosis.
• Stigma can be both internal (self) and external (close and wider community)
  Labelling and Stigma
• Wider society and mass media - continue to perpetuate stereotypes or minimise seriousness
  • The Shining and Psychosis
  • Serial killers and personality disorders
  • Flippant use of mental health terminology, e.g. “triggered”, “trauma”, “depressed”
• Community, friends & family - often unintentional (but not always), friends, family and others within our social network can:
  • Believe stereotypes
  • Attribute behaviours
  • Assume limitations or make unhelpful excuses
• Ourselves - as suggested by labelling theory
  • if we believe the stereotype, we create a self-fulfilling prophecy for ourselves limiting the potential we see for ourselves
  • We can make excuses or use a label as an avoidance strategy

Harms associated with labelling and stigma:

• Performative language:
  • = the power of language to perform a social action, such as prejudice, stigma
    • “You are so… ”
• Limiting language:
  • = the unhelpful limitations that hold individuals back from achieving their potential
    • “I can’t because… ” or “they can’t because”
• Labelling theory (sociology) and identity formation:
  • = internalised beliefs about self, conformity to the label, locus of control
    • “This is who I am and I have no control over it”
• Stickiness of labels:
  • = once given, hard to remove, behaviour is attributed and contextualised in relation to label rather than other factors such as environment (Rosenhan)
    • “They are acting that way because of their… ".

A CLOSER LOOK AT STIGMA - HOW MAD ARE YOU?

• This two-part documentary series aimed to recreate Rosenhan’s 1972 experiment in a search for the difference between the mentally ill and the supposedly sane.
• After watching the documentary we will analyse the experiences of the participants to consider the role of social factors in mental health.

Cognitive Perspective

• Developed by Aaron Beck.
• Beck noticed that when people were “free associating” it often involved similar, automatic, negative thinking patterns (negative self-talk)
• The thoughts are typically self-critical in nature and can devolve into cognitive distortions (as seen in the image).

Negative Self-Talk

• Negative self-talk feeds mental illnesses, including depression and anxiety.

• It does this is through the neural pathway creation of these thought patterns (neuroplasticity).

• These pathways strengthen through rumination – (replaying the thought over and over again in your head, not being able to turn it off)

• The cognitive approach suggests that we can use the same mechanisms that create negative self-talk, to change it through a process of identifying, challenging and substituting thought patterns.

Cognitive Treatment

Involves identifying, challenging and substituting thought patterns

1. Catch the thought - start to take notice when you are having intrusive thoughts, pay conscious attention to them

   • For example: “I didn’t get the job, I’m a total failure, I’ll never be good enough for anything”

2. Check its accuracy - assess the thought for how useful and realistic it is

   • For example: “I’m disappointed, but it doesn’t mean I’m a total failure”

3. Change the thought – substitute the negative thought for one that is more helpful and has a more positive outlook

   • For example: “I didn’t get this job, but there are other opportunities and better jobs for me”

Behavioural Perspective

• Mental disorders can result from conditioning.
  • Classical conditioning – PTSD
    • A car backfires (sounds like a gun) causing a person to re-live a traumatic memory.
  • Operant conditioning – OCD
    • In OCD, the performance of a compulsive behaviour acts as a “reward” by removing anxiety (negative reinforcement). 87 However this is only short-lived.

Behavioural Treatment

• Uses the principles of conditioning to change disruptive behaviours and improve human functioning.
• Useful for fears, anxiety and personality issues.
• Examples include:
  • Systematic desensitisation – client is gradually exposed to a feared object or situation
  • Aversion therapy – trying to change a behaviour by associating it with something negative

Cognitive Behavioural Therapies

• A combination of cognitive and behavioural therapy techniques.
• Changes maladaptive behaviour patterns along with the distorted thought patterns that underlie them.
  • Depressive disorders:
    • changing negative thought patterns whilst introducing helpful behaviour patterns, e.g. going for a walk everyday
  • Anxiety disorders:
    • visualisation techniques or role playing anxiety provoking scenarios

How it works:

• What does the client state is the problem?
• What did the therapist suggest?
• What was the client’s response?
• What needs to happen next?
• CRITICISMS CBT Complete the final question on the worksheet “Is CBT an appropriate treatment for mental illness?”

Historical Approaches to Mental Health

A timeline of treatment approaches

Pre Institutionalism Treatments for Mental Illness:

Treatment approaches prior to the 19th Century

• Trephination

  • What was it and how was it thought to work?

  • Humoral theory and purging

    • What was it and how was it thought to work?

The Institutionalism (Asylum) Era:

Treatment approaches during the 19th and 20th Centuries

• Mental Asylums

  • What were they and why were they used?

• Shock Treatments - e.g. Insulin Coma Therapy

  • What was it and how was it thought to work?

• Psychosurgery - e.g. Lobotomy

  • What was it and how was it thought to work?

• Medications - e.g. Barbiturate therapy

  • What was it and why was it used?

The Post Institutionalism Era:

21st Century Treatment - The Biopsychosocial

• Biological

  • What is the biological approach to treatment and why is it important?

• Psychological

  • What is the psychological approach to treatment and why is it important?

• Social and Environmental

  • What is the Social (& environmental) approach and why is it important?

• The definition of mental health has been widened so much that it’s now almost meaningless Martha Gill

• In our newly aware world, serious conditions such as psychosis and schizophrenia are overlooked Sun 14 May 2023 18.32 AEST

• The psychiatrist Simon Wessely once said his spirits sank every time there was a mental health awareness week.

• “We don’t need people to be more aware. We can’t deal with the ones who already are aware, ” he said. Yet awareness spreads and propagates, even as queues outside psychiatrist offices trail around the block.

• This year’s big week, run by the Mental Health Foundation, starts on Monday. Its theme is anxiety, a disorder affecting a quarter of adults, according to the foundation – a statistic that sounds unbelievably large until you read its description of the condition, which seems almost broad enough to take in the full sweep of human experience.

• “Lots of things can lead to feelings of anxiety, including exam pressures, relationships, starting a new job (or losing one) or other big life events. We can also get anxious when it comes to things to do with money and not being able to meet our basic needs, like heating our home or buying food. ”

• Britain is certainly more aware than it used to be.

• Diagnoses have broadened – more of us see grief and stress as mental illnesses than we did a decade ago.

• Therapy-speak infuses the language: triggering, boundaries, projection, self-care – stiff-upper-lipped Brits have expanded their vocabularies.

• This slow medicalisation of our lives has attracted criticism but surveys show it seems to have had a positive effect: discrimination and negative reactions to mental illness are increasingly taboo.

• People feel able to seek the help they need without risking their jobs, relationships or social lives.

• Britain’s Time to Change campaign that ran for 14 years to 2021 was shown to have caused a “significant” drop in stigma.

• Mental health awareness has its limits.

• While attitudes towards milder and more common mental health conditions such as anxiety, low mood, stress or burnout have improved, more serious disorders such as schizophrenia and psychosis trail far behind. In fact, when it comes to schizophrenia, we seem to be getting less enlightened.

• A study of 10,000 people spanning the three decades to 2020 found that by nearly all measures, stigma towards the disorder had worsened. People were less likely to want someone with schizophrenia as a housemate or co-worker than in 1990. They felt more fear and less desire to help. Other research backs this up. Some 88% of people with severe mental illness say they experience stigma. Few people would recommend someone living with schizophrenia for a job, and even mental health professionals hold negative attitudes towards them. A study last month, meanwhile, found that one in three people living with sufferers of severe mental illness were themselves discriminated against.

• Why this hierarchy? These two-track attitudes are everywhere. While nearly all employers acknowledge they have a responsibility towards their staff’s wellbeing, and promote mental health awareness, some 15% of employees still face dismissal or demotion after they reveal their mental health problem.

• There are also troubling reports that some mental illnesses are being weaponised. The army makes much of its “resilience” training and mental health resources. Yet a report in January alleged that female members of the armed forces who accused their colleagues of rape were being “misdiagnosed” with personality disorders in order to discredit their accounts.

• Media coverage does not help the cause of those with psychosis or other severe mental health issues: where they pop up in the news it is to most frequently be associated with (rare) violent incidents. And though psychology and psychiatry have for the last decade gripped the film industry – the traumatic backstory is a staple – psychosis still gets a bad press: it is the stuff of horror films and murder stories.

• In the United States, meanwhile, a narrative linking mental illness to gun violence is being pushed by some politicians. Following a mass shooting in a mall in Texas this month, Greg Abbott, the Republican governor, deflected pressure for gun control by calling for more mental health resources, defining these problems as the “root cause” . These narratives are skewed: the connection between violence and mental illness is weak at best. A recent scientific review into the link concluded that, even if psychotic and mood disorders were eliminated, “96% of violent acts would still occur” . But the stigma persists.

• Severe mental health disorders are therefore more in need of destigmatisation campaigns but get fewer of them. The theme of last year’s mental health awareness week was loneliness. Previous years have covered nature and mental health, kindness and body image. ITV’s Britain Get Talking campaign last year, Public Health England’s Every Mind Matters, and the NHS Help! campaign all focused on milder conditions, such as low mood and sleep problems, urging people to talk to those around them.

• These awareness campaigns seem to work by stretching the concept of mental illness into the realm of common experience – linking anxious feelings to anxiety, or relating depression to the stresses of everyday life. Researchers speculate the recorded improvement in attitudes is due to the less severe images that come to mind when answering survey questions: if everyone has experienced depression, the stigma goes. But there’s a problem here. It might be that campaigners have not “normalised” mental illness so much as broadened the definition to the point that it includes the mentally well. If the method of lessening stigma is to consider mental health disorders relatable and “sane” , reactions to a stressful environment, illnesses out of the realm of common experience, such as schizophrenia, are left out. And with so many new anxiety and burnout sufferers, there’s a risk that the severely ill are crowded out of the conversation altogether.

First Nations and Mental Health

Key Statistics:

• In 2018–19, over a third of First Nations people (37%) reported having a current mental health condition. The proportion was higher among females (42%) than males (30%).
• Influences on mental health: First Nations people diagnosed with a mental health condition were more likely to report:
  • High/Very high psychological distress (53%),
  • Low mastery (49%) - the level of control a person feels over their own life
  • Low perceived social support (13%)

First Nations Perspectives

• For First Nations peoples, good health is more than the absence of disease or illness
• It is a holistic concept that includes physical, family and social, mental and emotional, cultural and spiritual wellbeing, for both the individual and the community.
  • Most Aboriginal and Torres Strait Islander communities prefer to define mental health as ‘social and emotional wellbeing’ .
  • This holistic concept recognises the importance of the complex connection to land, culture, spirituality, ancestry, family and community.
  • It also recognises the unique strengths of Aboriginal and Torres Strait Islander cultures, especially the role extended family and community can play in healing practices.

First Nations Perspectives

• Comparisons between a western medicine approach and a First Nations approach

Western Medical Approach

• Takes a clinical perspective and categorises mental health as an illness
• Often distinguishes between physical and mental health
• An individualistic experience, focus on an individual’s interaction with their environment

Aboriginal and Torres Strait Islander Approach

• Defines mental health as social and emotional wellbeing, and good mental health is indicated by feeling a sense of belonging, having strong cultural identity, maintaining positive interpersonal relationships, and feeling that life has purpose and value
• Involves a holistic approach that encompasses physical, family and social, mental and emotional, cultural and spiritual factors
• Healing practices involve the extended family and community. It also involves connection to country.

Enhancing Social and Emotional Wellbeing

• First Nations culture and self-determination (an ongoing process of choice) can be powerful protective factors in providing a buffer to psychological distress.
• Factors that have been identified as enhancing SEWB include:
  • Maintaining connection to country
  • Spirituality
  • Ancestry and kinship networks
  • Strong community governance and cultural continuity [11].
• Renewal of Aboriginal and Torres Strait Islander culture and Indigenous knowledge systems and the capacity for self-determination is increasingly being seen as fundamental to healing and supporting SEWB [12].

Zubrick, S.R. , Shepherd, C.C.J. , Dudgeon, P. , Gee, G., Paradies, Y. , Scrine, C. , Walker, R..(2014).

• Social determinants of social and motional wellbeing. In Dudgeon, P. Milroy, H. Walker, R. (Ed.), Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice (2nd edition ed.,pp. 93-112). Canberra: Department of the Prime Minister and Cabinet.

Dudgeon, P., Bray, A., Smallwood, G., Walker, R., Dalton, T. (2020).

• Wellbeing and healing through connection and culture. Sydney: Lifeline.

Things to Consider

• First Nations peoples are culturally and linguistically diverse and not all families and communities share the exact same concept of mental health.
• These expressions may change across an Aboriginal and Torres Strait Islander person’s life course, so what is important to a child may be quite different to what is important to an Elder.
• Therefore, it is important to learn the unique story of the family and community being worked with and seek advice from the family, community, Elders and Aboriginal and Torres Strait Islander practitioners to best understand how the community might approach concepts of social and emotional wellbeing and mental health.
  What mental health means to aboriginal and torres strait islander communities | child safety practice manual. (2021, July 5). https://cspm.csyw.qld.gov.au/practice-kits/mental-health/working-with-aboriginal-and-torres-strait -islander/seeing-and-un derstanding/what-mental-health-means-to-aboriginal-and-torres#AboriginalandTorresStraitI slanderpeoplesarediver sewithmanyperspectives Activity Complete the activity on the Google Classroom “Questions - First Nations Perspectives and Mental Health”

6 Social Determinants of Social and Emotional Wellbeing

• Stephen R. Zubrick, Carrington CJ Shepherd, Pat Dudgeon, Graham Gee, Yin Paradies, Clair Scrine and Roz Walker

Overview

• This chapter explores current understandings of the social determinants of Aboriginal and Torres Strait Islander social and emotional wellbeing and its development.

Theoretical Frameworks

• We show that the determinants of this wellbeing are multiple, interconnected, and develop and act across the lifecourse from conception to late life.
• This chapter firstly focuses on the theoretical frameworks linking social factors to health and their applicability in Aboriginal population contexts.

Broad Mechanisms

• It then examines how social and emotional wellbeing develops in individuals, with a specific focus on the broad mechanisms that prompt, facilitate or constrain social and emotional wellbeing in all individuals.

• The chapter then discusses the social determinants and processes that pose a risk to the development of poor outcomes among Aboriginal and Torres Strait Islander peoples as well as the factors that promote or protect positive wellbeing.

• We highlight that there are a unique set of protective factors contained within Indigenous cultures and communities that serve as sources of strength and resilience. It should be noted that this chapter primarily examines and refers to ‘social and emotional wellbeing’, as opposed to the terms ‘mental health’ or ‘mental illness’ .

• The social and emotional wellbeing concept reflects the broader, holistic view of health that is an intrinsic part of Aboriginal and Torres Strait Islander (herein referred to as ‘Aboriginal’) culture. It recognises the importance of connection to land, culture, spirituality, ancestry, family and community, and how these affect individual’s wellbeing.1

INTRODUCTION

• What can be done to promote and protect the development of optimal social and emotional wellbeing (SEWB) among Aboriginal peoples?
• How is the development of poor SEWB prevented or reduced?
• To begin to address these questions it is necessary to have an understanding of the key determinants of the wellbeing of populations.

THE IMPORTANCE OF SOCIAL FACTORS TO POPULATION HEALTH

• The health and development of individuals is shaped by an array of factors over time and by place and lifecourse stage. Genetic history, biology and environmental exposures can all have a marked impact on health, and form part of the complex aetiologies of physical and mental health problems.2, 3 In recent decades there has been an increased acknowledgment of the role of social factors in determining health outcomes.

• There is now a robust international literature that consistently affirms that social factors have a marked influence on the health of populations. The quantitative and qualitative evidence base now widely supports the notion that health inequalities, such as those that exist between Aboriginal and non-Aboriginal Australians, are the result of factors and processes that fall outside of the traditional domains of health. They are heavily influenced by the structures of society and the social conditions in which people grow, live, work and age—or what are now popularly known as the social determinants of health.4

• These social determinants of health comprise a wide range of factors, including those that describe the material and social environment of families and the communities in which they live, and the psychosocial conditions of life. These factors extend to income, employment, occupation, poverty, housing, education, access to community resources, and demographic factors such as gender, age and ethnicity.5

• There are a number of theoretical frameworks that attempt to describe the relationship between health and their social determinants. Most place an emphasis on either psychosocial processes that increase an individual’s susceptibility to illness (for example, lower social standing that causes stress, leading to alcohol misuse and a perceived loss of control over one’s life, and consequent poor health), or broader economic and political influences that have an indirect effect on health via their impact on material wellbeing (for example, financial strain that results in restricted access to health care services), or both.

• Importantly, most determinants do not occur in isolation from others. Many pose a risk to health concurrently and many accumulate as time goes on. The number and type of risks (or protective factors) faced by an individual, and their timing, intensity and duration of exposure all influence the level of wellbeing experienced at any point in time. The framework posed by the World Health Organisation’s Commission on Social Determinants of Health (WHO CSDH) is a prominent example of an organising framework that implicates the circumstances of daily life and the broader structures of society as important health determinants.6 It highlights that inequalities in society lead to inequalities in physical and mental health.7

• The elements of the WHO CSDH framework were determined on the basis of the empirical evidence globally and features determinants that have been shown to be amenable to policy intervention. In other words, the generally accepted social determinants of health are modifiable—that is, they can be influenced or controlled in ways that either reduce the incidence and/or prevalence of ill health and disease, or promote the likelihood of positive physical and mental health and wellbeing. The WHO CSDH framework and its components are likely to have applicability to Aboriginal populations,7-9 although it should be recognised that while the framework makes reference to ethnicity and race as a key determinant of health, they are not a central tenet. Models that consider specific population groups tend to place greater emphasis on characteristics of culture and historical circumstances. The model proposed by Williams (1997), for example