The Social Ecology of Psychotherapy: Community-Level Influences on Adolescent Mental Health Treatment

Effective treatment for depression and anxiety in adolescence is a public health concern. Although psychotherapies for depression and anxiety exist, youth psychotherapies are less effective when delivered in community settings compared to research settings. A social-ecological model, which considers individual-, interpersonal-, and community-level influences on wellbeing, posits that understanding multi-level factors can help us understand this drop in treatment effectiveness. This study employs a socioecological model to examine the influence of neighborhood factors on depression and anxiety treatment for adolescents receiving psychotherapy in community mental health clinics, after controlling for relevant individual- and interpersonal-level factors.

Demographic and clinical data from a sample of 196 adolescents undergoing mental health treatment were gathered from a two-site, randomized controlled effectiveness trial. The parent study was a 3-arm trial of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) and measurement-based care (MBC) compared to treatment as usual (TAU). All three study arms were combined for analysis. Adolescents completed a baseline assessment with an independent evaluator upon treatment initiation, and follow-up assessments at 8, 16, and 28 weeks. Individual-level variables (youth age, gender, race/ethnicity), family-level variables (household income, caregiver psychopathology, and parenting behavior), and neighborhood-level variables from the U.S. Census Bureau American Community Survey (ACS) were combined for this secondary analysis. A composite neighborhood disadvantage index consisting of seven ACS variables was used as a predictor of adolescent symptom severity and psychotherapy outcomes in multilevel models.

Consistent with a social-ecological model, results revealed multi-level influences of adolescent symptom severity and treatment outcomes. Neighborhood disadvantage was associated with higher symptom severity (β  = .03, 95% CI [.01, .04], p = .004) and poorer treatment improvement from the 16-week to 28-week follow up assessment (OR = 1.13, 95% CI [1.02, 1.26]). Parent psychopathology played an important role in youth functioning, with higher caregiver depression predicting greater youth impairment at all timepoints (p < .01).

Findings support the relevance of community factors as structural determinants of adolescent mental health symptoms and psychotherapy outcomes. Applying a multi-level lens that considers contextual factors is critical in the study of youth psychotherapy.