Introduction by Croakey: Psychological distress and levels of life satisfaction in Australia have not returned to pre-pandemic levels, although they have improved since 2021, according to the latest report card on Australia’s wellbeing.
The report also shows that during the same period rental, housing and cost-of-living expenses have all increased, all critical determinants of health.
Below, Max Loomes, researcher at UNSW and mental health advocate, argues that more attention needs to be paid to addressing the social determinants of mental health, and calls for mental health practitioners to get behind “psychotherapy that places social justice at the front and centre”.
Max Loomes writes:
Every day we are reminded about Australia’s growing mental health crisis. One in five Australians has experienced a diagnosable mental health condition in the past 12 months, with this set to increase each year.
As a therapist and researcher, I’ve seen the effects firsthand. So many people are distressed and unwell. They are pressurised by the pandemic, climate change, skyrocketing cost of living. Additionally, people who are exposed to systematic violence and discrimination experience substantially more distress.
Numerous evidence-based interventions exist to help – medication, psychotherapy, and even lifestyle interventions. Each tries to alleviate the pain and suffering and facilitate meaningful change in a person’s life that could aid in their recovery. Yet, it’s seemingly an effort of Sisyphean proportion.
As my knowledge of mental health has evolved, what I’ve realised is that these interventions are grossly insufficient. They don’t address the social determinants of health that influence whether someone experiences poor mental health. These social determinants are demographic factors, or decisions of power-holders or results of government policies that make individuals susceptible to mental health concerns, stress, or violence.
Social determinants are usually impactful during childhood but are cemented through prolonged exposure. For example, families facing multiple challenges like maintaining multiple jobs, piling credit card bills, housing insecurity and stagnant wage growth against a rising cost of living are more likely to experience mental ill-health.
The effects of colonisation on Aboriginal and Torres Strait Islander people are another prime example of SDOH. Centuries of colonialist legislation, policies and practices has caused harm amongst Aboriginal and Torres Strait Islander individuals and communities, which has transcended generations.
It makes sense that available interventions don’t always work – they assume stability and access to social, temporal and economic capital.
Addressing social determinants
So, what is the solution? Well, it’s clear that the social determinants need to be addressed. While political advocacy occurs every day, there is still significant ignorance and lack of action from within the mental health system, which definitely needs to change.
Politically, this is not a problem – research shows that choosing a career in the mental health sector is linked to progressive ideology and a belief in social justice. However, throughout their training, mental health workers are often encouraged to maintain political and social neutrality when conducting therapy.
We know this is impossible, with every opinion and experience shaping how therapy is performed. Even the choices of therapeutical modality can be political.
The most common type, Cognitive Behavioural Therapy, purports to change unhelpful thoughts, feelings, and behaviours within the individual. For many, indeed this is correct, with it engendering meaningful change and help to lower psychological distress.
But for others, especially those experiencing systemic violence, this could inadvertently act to gaslight them. It says to the individual that their circumstances cannot be changed, so they must change instead.
Justice oriented therapy
Instead, what we need is a new form of psychotherapy that places social justice at the front and centre.
I propose a therapeutic form of advocacy that encourages dismantling inequalities and replacing them with equalised power structures. It could be called Justice Oriented Therapy (JOT). JOT appropriates therapeutic aspects from its predecessor, CBT, by building personal resources through self-care.
Therapists and consumers would work collaboratively to meet basic needs – including welfare and other supportive needs – resolve interpersonal conflicts and make the consumer feel heard through counselling techniques like validation and active listening.
Once a consumers’ personal resources are replenished, they will be encouraged to advocate for changes to societal circumstances instead of changing themselves. How this occurs depends on the individual, their personality, their capacity, and their values. It may be driven by the consumer, supported by the therapist or by mobilising practitioners, acknowledging that advocacy and activism may be a burden on some people who are unwell or struggling to create change.
A singular act does not define social justice – everybody has a role to play. Some may attend protests against government inaction on climate change, institutional corruption or violence. Others may prefer subtle community or awareness building, perhaps linked to their ethnicity, culture, religion or spirituality.
These actions and activism could be an antidote to fear, helplessness, and hopelessness.
Role of mental health professionals
Of course, this concept of social justice in mental health is not a novel one. It stands upon a long history in academic and clinical realms, such as the antipsychiatry movement starting in the 1980s, as well as the recent shift towards paradigms of lived experience. However, no evidence-based treatment has been ‘legitimised’ through a scientist-practitioner lens.
For clinical practitioners to use it in their everyday practice, they would require it to be 1) based on pre-existing research, 2) trialled by a randomised control trial, and 3) show statistically and clinically meaningful change for consumers.
The mental health professional plays a pivotal role in this process – they act as a conduit to change. They must build awareness through psychoeducation, encourage meaningful action based on values, and still help the consumer behave in a way that will improve their mental health, not let it worsen.
For this to happen, therapists must also believe in tenets of social justice. They must be aware of social injustices and how they relate to mental health. Education about injustice, sociology and SDOH should be integrated into all tertiary psychology and mental health curricula, in the same way that diagnostic manuals and their importance are taught.
My own interest and involvement in activism developed during this time at university, and has been pivotal in my growth as both a mental health professional and an activist.
It’s inspired me to work on campaigns for marriage equality and equity within religious schools, researching within trauma space, and also co-founding the online community ‘Psychologists for Social Justice’ and an ensuing magazine labelled ‘The Activist Practitioner’.
Empowerment
Empowerment is the goal of this therapy. It demolishes the idea that the individual is impotent to their circumstances. They are not powerless, they are far stronger than they think.
It also aims to shift away from the individualism our mental health system perpetuates. Rather than solely changing themselves, consumers can find solace linking together to make meaningful societal change.
Of course, this type of therapy will not be for everybody. Some are currently too unwell to participate.
There will be others who fundamentally disagree with social justice as a concept.
As a budding therapist and researcher, I aim to create foundations for this type of therapy. This will require a thorough understanding of the theoretical underpinnings of social justice and psychotherapy and an enormous need to hear and share the voices of those with lived experience.
Times change, and practical measures are needed to change our society in a rapid yet evidence-based way. Will you join me?
Max Loomes is a researcher at UNSW. Max has a strong interest in activism in everyday life and through his clinical work. He is also a firm believer that trauma research should be done with those who have lived experience as they are the true experts in the field.
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See Croakey’s archive of articles on mental health.
Thanks for writing this up. I’m curious how JOT would be marginally different than other existing approaches such as case management? I would really suggest that you look into the extant social work literature, which has been developing this approach and may bolster your argument.
I agree. This is basically a description of social work – but has all of the same problems with the field – what does it mean to “empower?” How can this process be adequately measured?
But also – classic clin psych – reinventing something that already exists (usually under the auspices of “rigor”)
Hi Sofia!
JOT would be a self contained psychotherapy implementable by therapists in both public and private settings. I envisage it being particularly helpful as a one-on-one therapy, but it definitely could be adapted for groups.
I see it being an approach that fuses concepts of traditional psychotherapy (e.g. CBT) with case management approach. It may also be useful in situations where case management isn’t readily available, such as in cases where consumers may not meet the criteria for support from multidisciplinary public health teams.
Given that this is just an initial concept, if it can evolve into something more, I’ll definitely include and learn from the rich academic and clinical social work literature and perspectives!
Thank you!