In therapy, we naturally focus on what’s happening inside the client such as their thoughts, emotions, and behaviors. But what’s happening outside the therapy room can be just as influential. Factors like where a client lives, their access to stable housing, their job security, or whether they can afford healthy food. All of these external influences, known as social determinants of health (SDOH), play a powerful role in mental health and healing.

More and more, the mental health field is recognizing the impact these broader life conditions have on clients’ well-being. As therapists, understanding SDOH gives us a fuller picture of our clients' lived experiences and helps us adapt our approach to treat more holistically.

This guide is here to help you begin identifying and working with SDOH in your clinical practice. We’ll explore how these factors can affect progress, how to spot the signs when they’re at play, and how to incorporate that understanding into treatment planning.

Spotting the Invisible Load: When SDOH Show Up in Session

Sometimes what looks like resistance, avoidance, or a lack of motivation is actually something else entirely. A client who frequently misses sessions, struggles to complete assignments, or seems disengaged might be dealing with real-world challenges that aren’t immediately visible—like financial instability, food insecurity, or unreliable transportation.

• For example: One of your clients has started missing sessions and isn’t completing their therapy homework. On the surface, it might seem like they’re disengaged or not prioritizing therapy. But after a compassionate check-in, you discover they’ve been couch-surfing and spending nights in shelters. Their basic need for housing security is consuming most of their mental and emotional bandwidth, leaving little space for therapeutic work.

When we understand the role SDOH plays in our clients’ lives, we can shift from frustration or confusion to empathy and strategic support. By recognizing these underlying stressors, we’re better equipped to create realistic goals, adjust expectations, and connect clients with resources that can help lighten their load.

Domains of SDOH and Their Clinical Impact

Let's explore the main areas of SDOH and how they show up in the therapy setting:

• Economic Stability: Issues like job insecurity, poverty, and debt can cause chronic stress, decision fatigue, and limited access to care. Financial difficulties might make it hard for clients to afford therapy sessions or medication.
• Education and Literacy: Lower education levels can create obstacles in understanding health information and lead to internalized stigma around seeking help. Clients might feel embarrassed or have trouble engaging with psychoeducational resources and might have trouble understanding complex concepts or metaphors.
• Neighborhood/Environment: Factors such as community violence, lack of green space, and transportation issues can all affect mental health. Clients in under-resourced areas might miss sessions due to unsafe conditions,long transit times, or unreliable transit services.
• Healthcare Access: Limited or no insurance often leads to delayed diagnosis and lack of integrated care. Clients may arrive at therapy with more severe, untreated symptoms or chronic health issues that complicate treatment.
• Social and Community Context: Systemic racism, isolation, and lack of safe relationships can significantly impact well-being. Clients from marginalized groups may face additional layers of trauma, stress, and barriers to social support.

By viewing clients with an SDOH perspective, we gain insight into the intricate factors affecting their mental health. Screening for SDOH provides valuable context to enhance our case understanding and treatment planning.

De-pathologizing and Reframing Client "Resistance"

When clients appear resistant or noncompliant, it’s easy to fall into labeling their behavior negatively. However, shifting from this perspective to a systems-informed approach can help us see the broader context of their struggles.

Therapist bias, often stemming from unexamined privilege, can unintentionally reinforce systemic inequities. We might label a client as "resistant" when, in fact, they encounter significant barriers to treatment engagement due to their social and environmental circumstances.

Integrating socio-ecological models (SEMs) into case formulation offers a more comprehensive and compassionate approach:

• Multi-Level Perspective: SEMs allow us to view mental health as influenced by various levels, from individual factors to wider social and environmental contexts. This perspective helps us look beyond symptoms and consider the complex interaction of systems affecting our clients.
• Personalized Interventions: Understanding a client's unique social and ecological context enables us to tailor interventions to their specific needs and challenges. This might involve addressing family dynamics, connecting them with community resources, or advocating for policy changes that affect their well-being.
• Transdiagnostic Approach: SEMs identify processes that span multiple diagnoses, allowing us to design flexible interventions suitable for various mental health conditions. This holistic method supports resilience and healing on multiple fronts.

Including SDOH screenings like the Health Leads screening tool in the intake process can offer valuable insights into the systemic factors influencing our clients' lives. By asking about housing, employment, social support, and access to healthcare, we gain a more comprehensive understanding of their challenges and can adjust our treatment plans accordingly.

What Can Therapists Do? Micro-Level Clinical Interventions

When working with clients facing challenges related to social determinants of health (SDOH), we need to offer empathetic and practical support within our therapeutic relationship. Here are some practical strategies:

• Validating Lived Experiences: Recognize the specific difficulties your clients encounter due to their social and environmental situations. Listen attentively and reflect their feelings without making assumptions or over-identifying.
• Collaborative Problem-Solving: Partner with clients to pinpoint realistic goals and strategies suitable to their current circumstances. Break down larger issues into small, manageable steps, celebrating progress along the way.
• Motivational Interviewing (MI): Apply MI techniques to help clients explore their mixed feelings, increase motivation for change, and address complex barriers. MI uses a non-judgmental, empathetic approach that honors client autonomy.
• Open-Ended Questions: Invite reflection with questions like, "What concerns you most about your current situation?"
• Affirmations: Recognize strengths and efforts, such as, "Despite these challenges, you've shown incredible resilience."
• Reflective Listening: Echo their thoughts and feelings to show understanding: "It sounds like you feel overwhelmed trying to balance work and childcare."
• Summarizing: Recap main points to clarify goals and next steps: "Let's review what we've discussed and identify your priorities moving forward."
• Realistic Goal-Setting: Work with clients to set achievable objectives that consider their unique obstacles and resources. Avoid "toxic positivity" or pushing unrealistic expectations that could lead to disappointment or disengagement.

Remember, our role is not to solve all of our clients' SDOH challenges but to create a supportive space for growth and resilience within their current reality. SDOH screening helps us tailor our approach to meet each client's specific needs with empathy and understanding.

When and How to Bring in Resources or Collaborate with Systems

Once you've identified SDOH factors affecting your clients, it's important to connect them with appropriate resources and work with other professionals to provide comprehensive support. Here's how to approach this process:

• Coordinating with Other Professionals: Team up with case managers, medical professionals, school counselors, or housing advocates to address your clients' specific needs. Keep communication open and clearly define roles to ensure smooth collaboration.
• Case Managers: Work with case managers to link clients with social services, benefits, and community resources.
• Medical Professionals: Collaborate with doctors and psychiatrists for physical health concerns and medication management.
• School Counselors: Partner with school staff to support clients' educational needs and address learning challenges.
• Housing Advocates: Connect with housing organizations to assist clients facing homelessness or housing insecurity.
• Ethical Considerations in Advocacy: When advocating for clients, maintain appropriate therapeutic boundaries and prioritize their autonomy. Obtain informed consent before sharing information with other professionals and clarify your role as a therapist.
• Confidentiality: Discuss limits of confidentiality and obtain necessary releases before collaborating with other providers.
• Scope of Practice: Recognize the boundaries of your expertise and refer clients to specialists when needed.
• Client Empowerment: Encourage clients to advocate for themselves and make informed decisions about their care.
• Building a Local Referral Network: Develop a list of trusted resources in your area to quickly connect clients with needed services. Regularly update and expand your network for accuracy and diversity.
• Key Resources: Keep contact information for housing support, food banks, low-cost health clinics, and legal aid services.
• Networking: Attend local events, join professional organizations, and collaborate with colleagues to find new resources.
• Online Directories: Use online databases and resource guides to locate specialized services and support groups.

Effective SDOH screening involves not only identifying challenges but also linking clients with practical solutions. Working with a diverse network of professionals and maintaining a robust referral list enables you to provide holistic, culturally responsive care that addresses the complex realities of your clients' lives.

Therapist Self-Reflection and Bias Check

As therapists, our own experiences, identities, and unconscious biases can significantly shape how we approach clients and interpret their challenges. Engaging in ongoing self-reflection is important when considering the role of social determinants of health (SDOH) in our clients' lives.

• Examining Privilege and Power: Take time to consider your own relationship with privilege, power, and systems of oppression. Reflect on how your social identities (e.g., race, gender, class) may influence your perceptions and interactions with clients from different backgrounds.
• Identifying Blind Spots: Unexamined assumptions and biases can lead to misunderstandings, therapeutic misattunement, or even retraumatization. Regularly question your own beliefs and seek feedback from colleagues or supervisors to identify possible blind spots.
• Practicing Cultural Humility: Approach SDOH screening and treatment planning with humility, recognizing that you will never fully understand a client's unique cultural experiences. Maintain openness, curiosity, and respect for each client's background and perspective.
• Committing to Lifelong Learning: Continuously educate yourself about SDOH, health equity, and culturally responsive care. Attend workshops, read diverse literature, and seek out learning opportunities to expand your understanding of how social and environmental factors affect mental health.

Remember, self-reflection is an ongoing process, not a one-time event. Regularly check in with yourself, acknowledging both your strengths and areas for growth in providing SDOH-informed care. Cultivate humility, empathy, and a willingness to learn from your clients' diverse experiences. SDOH screening is just one part of a larger commitment to culturally responsive, socially just therapy practices.

Key Takeaways

Bringing SDOH screening into your therapy practice offers a meaningful way to provide more holistic, equitable care. By systematically assessing and addressing the social, economic, and environmental factors affecting your clients' lives, you can improve treatment effectiveness and support better health outcomes. Some key takeaways for SDOH-informed therapy include:

• Routine Screening: Add SDOH questions to your intake process and EHR system to consistently capture important social determinants.
• Sensitive Approach: Build trust and use patient-centered communication when discussing SDOH to create a safe, non-judgmental space.
• Team Training: Educate all staff on SDOH awareness and referral processes to facilitate a seamless, whole-person care approach.
• Standardized Tools: Use validated SDOH assessment tools and documentation systems to formalize attention to social factors in clinical records.
• Community Partnerships: Develop strong collaboration and referral networks to connect clients with vital support services and resources.
• Tailored Care Plans: Create individualized treatment plans that incorporate strategies to address identified social risks and barriers.
• Therapeutic Opportunities: Use therapy sessions as natural moments to explore SDOH, deepen understanding, and inform personalized interventions.

Remember, integrating SDOH is not just a clinical best practice but also an ethical responsibility. Providing care that responds to the full context of our clients' lives is key to promoting health equity and improving outcomes.

To further your journey toward SDOH-informed practice, explore these valuable resources:

• WHO SDOH Conceptual Framework
• CDC SDOH Training and Education
• APHA SDOH Resources and Advocacy