Social Obstacles to Change

1. Social Obstacles to Change The Intersection of Epidemiology, Neurobiology, and Clinical Practice with Veterans Katharine Bloeser, LICSW Kelly McCoy, PsyD

2. VANTS Line • To add in audio, call the VANTS line below from your telephone. Please be sure to mute your phone. 1-800-767-1750 Access Code: 71037

3. Social Determinants of Health What are social determinants of health? “The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system.” World Health Organization, August, 2008

4. The Biopsychosocial Model (1978)

5. The Biopsychosocial Model

6. Do social or environmental factors influence health outcomes? Social Capital and Glucose Control • Black Veterans living in Philadelphia • After controlling for individual factors (e.g., BMI, age), neighborhood poverty, and individual level mediators (e.g., medication adherence); those Veterans who reported that their neighborhood was a place where people worked together had a statistically significantly positive effect on HbA1c. Long, J.A., et al. (2010)

7. Do social or environmental factors influence health outcomes? 10 years later… Murdoch, M., et al. (2011)

8. Do social or environmental factors influence health outcomes? Veterans and Disability Employment status Work hours Government assistance Mental health and wellbeing National Poverty Center, April, 2011

9. Do social or environmental factors influence mental health outcomes? Neighborhood Violent Crime and Depression -Sample of current and former drug users -270 block groups within Baltimore, MD from 1997-1998 -Violence is associated with psychological distress through perceptions of neighborhood disorder and personal experiences of violence. Curry, A., Latkin, C., & Davey-Rothwell, M. (2008)

10. Do social or environmental factors influence mental health outcomes? Why does neighborhood violence impact depression? • Fear of crime and violence  less interaction among residents  social isolation • “Mood congruent bias” Depression  recall of more violence 3. Lack of financial means / Depression  move towards less safe or more depressed areas Curry, A., Latkin, C., & Davey-Rothwell, M. (2008)

11. Do social or environmental factors influence mental health outcomes? Neighborhood socioeconomic status and individual perceptions of efficacy -Bandura’s social cognitive theory defines self-efficacy, “people’s judgments of their capabilities to organize and execute a course of action required to attain designated types of performances.” Bandura (1986)

12. Boardman, J.D. & Robert, S.A. (2000)

13. Do social or environmental factors influence mental health outcomes? Maciejewski, P.K., Prigerson, H.G., Mazure, C.M. (2000)

14. Do social or environmental factors influence health outcomes? Formation of individual self-efficacy: • Reflective self: How individuals feel they appear to others. • Comparative self: How individuals feel they compare with others. • Observational self: How individuals view their behaviors. • Reflective self: “I must be not worth much, because my neighborhood is in such chaos. No one seems to care.” • Comparative self: “Everyone around me is just as depressed as I am, isn’t that normal?” • Observational self: “Its not like I contribute anything to people, why try?

15. Social Influences on Health: Foundational Research • Suicide(Durkheim, 1897) • A deeply “psychological” and “private” act influenced by social integration and cohesion • Suicide patterns explained by social facts • Anomic suicide • Attachment Theory (Bowlby, 1940s-1980s) • Importance of attachment bonds in early childhood to adult social development • Emotional development during childhood important to overall health In Berkman, Glass, Brissette & Seeman (2000)

16. Current Example: Military Sexual Trauma • “Victims are often forced to choose between continuing military careers during which they are forced to have frequent contact with their perpetrators or sacrificing their career goals in order to protect themselves from future victimization.” – VA National Center for PTSD website

17. Adult Social Attachments • Numerous epidemiological findings link adult social attachments to health outcomes • E.g., adult attachment style associated with symptom perception and health care utilization (Ciechanowski, Walker, Keaton, & Russo, 2002) • While early childhood development is important, adult socialization also has large ramifications • E.g., employment opportunities, social upheaval, work stress • Social factors influence adult neurobiology, cardiovascular heath, and other biological systems

18. What is “social support”? Berkman, Glass, Brissette & Seeman (2000)

19. What is “social support”? • Social and cultural context • Network structure • Quantity and structure of relationships • Quality of relationships • Types of support • Emotional: love, caring, sympathy, esteem, intimacy • Instrumental: material needs • Appraisal: assistance with decision making • Informational: provision of advice or information

20. What is “stress”? • Stress is perceived by the brain • Responses to stress can be adaptive or maladaptive • Brain initiates behavioral and physiological responses to stress • The stress response involves communication between brain, cardiovascular, immune, autonomic, and endocrine systems

21. Figure 1.Non-linear network of mediators of allostasis involved in the stress response. Arrows indicate that each system regulates the others in a reciprocal manner, creating a non-linear network. Moreover, there are multiple pathways for regulation – e.g. inflammatory cytokine production is negatively regulated via anti-inflammatory cytokines, as well as via parasympathetic and glucocorticoid pathways, whereas sympathetic activity increases inflammatory cytokine production. Parasympathetic activity, in turn, contains sympathetic activity. Reprinted from McEwen 2006 by permission. Environmental factors e.g., Access to healthy foods Exposure to war, death, and destruction Social isolation Exposure to toxins Child abuse Insufficient finances Unsafe living conditions Occupational stress McEwen (2009)

22. Effects of Social Environment on Personal Health • Neurobiology • Structural remodeling • Cardiovascular health • Metabolic changes • Immune function • The immune-brain loop • Life expectancy • Telomere length

23. What about “good” stress? • Eustress versus distress • Common examples of eustress: • Meaningful community participation, overcoming a challenge, physical exercise, competing in a tournament, advocacy work

24. Social and Psychological Interventions Help • Changes in brain structure in response to stress can be reversed • Behavioral and social factors promote resilience • Evidence of changed brain functioning in response to psychotherapy • Evidence of increased telomerase activity following lifestyle change in men with prostate cancer (Ornish et al., 2008) • Social and behavioral interventions “reduce the chronic stress burden and benefit brain and body health and resilience” (McEwen, 2009)

25. Effects of Illness and Injury on Social Cognition • Specific illnesses and injuries are associated with restricted social support • Some illnesses and injuries are also associated with difficulty processing social information • e.g., traumatic brain injury, frontotemporal dementia, autism, schizophrenia • In both cases, rehabilitation includes development of enhanced social support

26. The Biopsychosocial Model (1978)

27. Person Level Interventions • Awareness of effects of social hierarchy in clinical encounters • Prevent experiences of rejection • Promote experiences of caring and esteem • Awareness of importance of social interactions on health • Provide emotional, instrumental, appraisal, and informational support • Assess past and present social experiences and their influence on current health and health behaviors • Patient-centered care approaches that emphasize Veteran empowerment and patient-provider relationship

28. Local Community Interventions • Facilitate development of health-promoting social networks for Veterans • Prevent provider burnout through healthy relationships at work • Appreciate the importance of social influences on behavior change • Provide green space in the local setting • Provide access to resources and education for Veterans • Connect the dots between health care and social services • Promote Veteran empowerment and involvement in decision making • Study and address health care and other benefit inequities

29. Larger Community Interventions • Advocate for political decisions that promote healthy communities • Advocate for political decisions that promote income and health care equality • Look for and address institutional discrimination • Promote adequate access to healthy foods and health education for people of all income levels • Promote cultural norms that reflect values of respect for all people, physical exercise, stress reduction, work-life balance, and holistic health care

30. Using Social Determinants of Health to Guide Interventions: Some examples • Informing policy, • Mental Health Impact Assessment (MHIA) Englewood, Chicago, Illinois

31. Neurobiology and Policy • “Finally, it should be noted that the social and physical environments in which we live are, at least in part, the products of practices and policies of private enterprise and government and these can be changed by changing those policies. Indeed, virtually all of the policies of government and business have powerful effects on health. Indeed, they have a top down effect via the brain on all the physiological systems involved in stress and adaptation (McEwen, 2007). Therefore, monitoring how the brain is affected by such policies is another important future direction of neuroimaging research because animal models can only give clues, but the study of the adaptability of the human brain is the ultimate goal!” (McEwen, 2009)

32. Harlem Children’s Zone • “By addressing the needs of the entire community, Harlem Children’s Zone isn't simply helping children beat the odds, it's helping to change theodds.”

33. Veterans’ Horticulture Initiative

34. Resurrection After Rape (Atkinson, 2010) • Interventions combine cognitive processing therapy with a social justice approach • “Rape is a social problem, not individual pathology” • Appropriately acknowledges the roles of politics and culture in sexual trauma and recovery • E.g., addresses unhealthy social norms including those that blame the victim, addresses rape as a men’s issues as much as it is a women’s issue, community engagement

35. Veteran Webinar • “Life Through the Eyes of Wounded Warriors” • Veteran presentation as part of Patient Care Services Grand Rounds • Mutual benefit to Veterans (self-efficacy) and VA employees (informs policy)

36. Veteran-Driven Research

37. Question for the Audience • Are there any initiatives you have undertaken that illustrate the principles of social determinants of health?

38. Resources World Health Organization (WHO) Commission on Social Determinants of Health http://www.who.int/social_determinants/en/ VA Center for Health Equity Research and Promotion http://www.cherp.research.va.gov/ HHS National Partnership for Action to End Health Disparities http://minorityhealth.hhs.gov/npa/

39. References Atkinson, M. (2010). Resurrection after Rape: A guide to transforming from victim to survivor. Oklahoma City, OK: Resurrection After Rape Publishing Bandura, A. (1986). Social Foundations of Thought and Action. Englewood Cliffs, NJ: Prentice-Hall. Berkman, L. F., Glass, T., Brissette, I., & Seeman, T. E. (2000). From social integration to health: Durkheim in the new millennium, 51(6): 843-857. Boardman, J. D., & Robert, S. A. (2000). Neighborhood socioeconomic status and perceptions of self efficacy. Sociological Perspectives, 43(1): 117-136. Ciechanowski, P. S., Walker, E. A., Katon, W. J., & Russo, J. E. (2002). Attachment theory: A model for health care utilization and somatization. Psychosomatic Medicine, 64: 660-667 Curry, A., Latkin, C., & Davey-Rothwell, M. (2008). Pathways to depression: The impact of neighborhood violent crime on inner-city residents in Baltimore, Maryland, USA. Soc Sci Med, 67(1)L 23-30.

40. References (cont.) Long, J. A., Field, S., Armstrong, K., Chang, V. W., & Metlay, J. P. (2010). Social capital and glucose control. Journal of Community Health, 35(5): 519-526. Maciejewski, P. K., Prigerson, H. G., & Mazure, C. M. (2000). Self-efficacy as a mediator between stressful life events and depressive symptoms: Differences based on history of prior depression. British Journal of Psychiatry, 176: 373-378. McEwen, B.S. (2009). The brain is the central organ of stress and adaptation. Neuroimage, 47(3): 911-913. Murdoch, M., Sayer, N. A., Spoont, M. R., Rosenheck, R., Noorbaloochi, S., Griffin, J. M., Arbisi, P. A., & Hagel, E. M. (2011). Long-term outcomes of disability benefits in US veterans with posttraumatic stress disorder. Arch Gen Psychiatry, 68(10): 1072-1080. Ornish, D., Lin, J., Daubenmier, J., Weidner, G., Epel, E., Kemp, C., Magbanua, M. J., Marlin, R., Yglecias, L., Carroll, P. R., & Blackburn, E. H. (2008). Increased telomerase activity and comprehensive lifestlye changes: A pilot study. Lancet Oncology, 9: 1048-1057.