interfaces between social and clinical psychology past, current, and future directions michael w....

Interfaces Between Social and Clinical Psychology

Past, Current, and Future Directions

Michael W. Vasey

Overview Brief history of the social-clinical interface Current state of the field: A brief and

selective review Some potentially fruitful future directions

Broad range of possibilities but particular focus on: Those emphasized by NIH Those currently most feasible at OSU

Selected Resources

Kowalski & Leary (1999) The Social Psychology of Emotional and

Behavioral Problems Kowalski & Leary (2004)

The Interface of Social and Clinical Psychology: Key Readings

History of the Social-Clinical Psychology Interface (Kowalski & Leary, 1999)

Generalist phase (1900-1945) Social and Clinical emerged as distinct specialties in

the ’40s Mutual disinterest (1946-1960)

Different emphases and methods: Social psychology – emphasized role of situational

influences on “normal” behavior Carefully controlled quantitative laboratory studies

microscopically focused on particular behaviors Clinical psychology – emphasized mainly

intrapsychic influences on “abnormal” behavior Less well-controlled field studies – typically reflecting a

more qualitative and holistic approach.


Early pioneers (1961-1975) Emphasized social psychology’s relevance for

understanding and developing effective approaches to psychotherapy

Jerome Frank (1961): Persuasion and Healing Viewed all psychological change as the result of

similar interpersonal and cognitive processes Emphasized factors such as attitudes, attributions,

self-efficacy, and demoralization Common Factors

“Shared components of psychotherapy that combat demoralization” (more about these later)


Early integrations (1976-1989) Brehm (1976) – The Application of Social

Psychology to Clinical Practice - argued for the relevance of social psychological theories to psychotherapy

Theories considered included: Reactance Theory Dissonance Theory Attribution Theories


Illustrative topics in Brehm’s book: Reactance Theory:

Persuading the client Paradoxical effects and minimizing reactance (resistance)

Dissonance Theory Therapeutic improvement as counterattitudinal behavior Therapeutic improvement as a means of dissonance

reduction Example: Clients who commit to therapy under conditions of

high choice and with forewarning of high effort required should reduce dissonance by believing in the therapy.

Attribution Theories Attribution as an integral part of emotional experience Redirecting attributions as a means of changing a client’s

emotional experiences.


Early integrations (1976-1989) Weary and Mirels (1982) – Integrations of

Clinical and Social Psychology Brought the social-clinical interface to a

wider audience Structure of the book made clear social

psychology’s relevance not only for psychotherapy but also for: clinical assessment and decision-making understanding of factors contributing to the

development, maintenance, and intensification of maladaptive behaviors


Late 70’s and early ’80s Shift of attention away from the early emphasis

on psychotherapy New emphasis was on social psychological

factors involved in the etiology, maintenance, and intensification of dysfunctional behavior (Weary, 1987)

Example: My first AABT conference in 1984

Research on concepts such as attributions and self schemas in depression seemed to be everywhere

Current State of the Field

A Brief and Selective Review

Three Domains in the Social-Clinical Interface (Kowalski & Leary, 1999) Social-Dysgenic Processes

Interpersonal, social-cognitive, and personality processes involved in the development, maintenance, and exacerbation of dysfunctional behavior and emotions

Social-Diagnostic Processes Interpersonal, social-cognitive, and personality

processes involved in the identification, classification, and assessment of psychological problems Also in perceptions and beliefs about such problems in

both professionals and laypeople Social-Therapeutic Processes

Interpersonal, social-cognitive, and personality processes involved in the prevention and treatment of emotional and behavioral difficulties

State of Research on Social-Dysgenic Processes Well-advanced

This is where the action has been for the past 20 years.

Especially work focused on: Depression Social-cognitive processes

Smaller but growing literatures on: Problems other than depression (especially

anxiety disorders) Interpersonal interactions and relationships

Interesting to note that the increased interest in such factors has not been driven by social psychologists

State of Research on Social-Dysgenic Processes

Several excellent sources on such research from a clinical perspective: Harvey, A., Watkins, E., Mansell, W., & Shafran, R. (2004).

Cognitive behavioural processes across psychological disorders: A transdiagnostic approach to research and treatment. Oxford: Oxford University Press.

Also an excellent introduction to the theory and practice of Cognitive-Behavioral Therapy (CBT)

Pettit, J. W., & Joiner, T. E. (2005). Chronic Depression: Interpersonal Sources, Therapeutic Solutions. Washington, DC: APA.

Also an excellent introduction to the theory and practice of the Interpersonal Therapy approach.

State of Research on Social-Dysgenic Processes: Examples Social-Cognitive Processes:

Attributions in depression Learned helplessness theory of depression (Abramson

et al., 1978) Hopelessness theory of depression (Abramson et al.,

1989) Predicts duration and pervasiveness of depressive

symptoms based on: Stability and globality of person’s attributions for

negative events Generalized hopelessness expectancies generate a

specific subtype of depression Characterized by:

Increased interpersonal dependency Decreased self-esteem Apathy and lethargy

State of Research on Social-Dysgenic Processes: Examples Social-Cognitive Processes

Attention Self-focused attention

Common to many disorders Selective attention for threat in anxiety

Social phobia and bias for angry faces (e.g., Gilboa-Schectman et al., 1999)

Memory Selective memory for negative information in

depression (e.g., Matt et al., 1992) Overgeneral memory in depression and PTSD

(e.g., Williams & Broadbent, 1986)

State of Research on Social-Dysgenic Processes: Examples

Social-Cognitive Processes: Interpretation Biases

Ambiguous information interpreted as threatening in anxiety (e.g., Mathews et al., 1989)

Expectancies Overestimation of the likelihood of negative

events in GAD patients (e.g., Butler & Mathews, 1983)


Intrusive Thoughts Thought suppression and intrusive worry and

rumination Example: Efforts to suppress trauma-related

thoughts after an auto accident predicts PTSD symptom severity at 1- and 3-years post-trauma (Ehlers et al., 1998; Mayou et al., 2002)

Metacognitive beliefs, awareness and regulation (Wells, 2002) Reference: Wells, A. (2002). Emotional disorders and

metacognition : Innovative cognitive therapy. New York: Wiley.


Social-Cognitive Processes: Cognitive and behavioral avoidance (Harvey et

al., 2004) Prevents exposure to corrective information

Safety-aids and safety-maneuvers (Harvey et al., 2004) Panic disorder with agoraphobia often

associated with dependence on a trusted person who serves as a safety aid. Such safety aids are thought to protect the person’s

catastrophic beliefs about the dangers of a panic attack from disconfirmation.


Deficient self-regulation (Baumeister & Vohs, 2004) Due to either situational or dispositional factors

(or both) Common to the vast majority of clinical

problems Prototypic example: ADHD But also relevant to anxiety, depression, eating

disorders, personality disorders, etc. Example from my current work

Risk for anxiety and depression is a function of positive and negative affective reactivity moderated by effortful control

NA X EC and PA X EC Interactions Predicting CDI Depression

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Interpersonal interactions and relationships:

Interpersonal theory of depression (Coyne, 1976): Main elements:

Depressed people tend to elicit negative reactions from others

Depressed people are often low in social skills and their own behavior contributes to the high levels of stress they experience

Excessive reassurance seeking is a critical interpersonal variable in depression

Well-supported by research (see Joiner, 2002) Reference: Joiner, T. E. (2002). Depression in its interpersonal

context. In I. H. Gotlib & C. L. Hammen (Eds.), Handbook of depression (pp. 295-313). New York: Guilford.


Interpersonal interactions and relationships: Self-verification theory and vulnerability

to depression Joiner (1995) demonstrated that college

students who both sought and received negative feedback from their roommates were at heightened risk for later depression

Reference: Joiner, T. E. (1995). The price of soliciting and receiving negative feedback:

Self-verification theory as a vulnerability to depression theory. Journal of Abnormal Psychology, 104, 364-372

State of Research on Social-Dysgenic Processes: Examples Interpersonal interactions and relationships:

Expressed emotion (EE) and relapse in schizophrenia (Butzlaff & Hooley, 1998) What is expressed emotion?

Criticism: Critical comments directed toward the patient

Hostility: Statements of dislike or resentment directed toward the patient

Emotional overinvolvement / overconcern / overprotectiveness

Relapse significantly more likely for individuals in high EE families.

State of Research on Social-Diagnostic Processes

Research on social cognitive processes in clinical judgment is well-developed Reference:

Garb, H. N. (1998). Studying the clinician: Judgment research and psychological assessment. Washington, DC: APA.

Research on social factors and other aspects of assessment and diagnosis is not well-developed.

State of Research on Social-Therapeutic Processes

Not well-developed Despite early focus on the potential

value of applying social psychological theories to the practice of psychotherapy, very little systematic work has been done

As Brehm pointed out 30 years ago, there is much potential here for social psychologists to make important contributions to psychotherapy.

Some Potentially Fruitful Future Directions

Future Directions in the “Social-Dysgenic” Domain Enhance current models by applying new social

psychological theories and concepts This work sometimes reflects limited knowledge of relevant

aspects of social psychology by clinical psychologists Extend existing work on social-cognitive and interpersonal

factors to clinical populations Much of this work is limited to analog samples

If findings generalize to clinical cases, relevant theories can be extended with confidence

If findings differ in clinical cases, should lead to more sophisticated understanding of relevant processes. Example: Dan Strunk’s research on depressive realism

Extend work on social factors to varieties of dysfunction heretofore ignored This process has begun but most work remains limited to

depression and anxiety.

Future Directions in the “Social-Diagnostic” Domain Enhance the clinical utility of existing assessment

instruments and techniques Develop new assessment instruments or techniques

(Translational research) Laboratory-based assessments of relevant social-

cognitive processes and patterns of interpersonal interactions and relationships.

Improve success of efforts to disseminate empirically-supported approaches to assessment

Improve success of efforts to reduce the use of psychometrically inadequate assessments

Enhance understanding of the structure of various problem domains

Future Possibilities in the “Social-Therapeutic” Domain

Improve understanding of the factors contributing to the efficacy of existing interventions

Enhance the efficacy, effectiveness, or efficiency of existing interventions

Develop new interventions (Translational research)

Improve success of efforts to disseminate empirically-supported treatments

Improving Understanding of Existing Interventions

Two main aspects of interventions to consider: Common factors Specific ingredients

Emphasis on cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT) may be most productive They account for the majority of current ESTs They are based on models of dysfunction that

emphasize social psychological factors

Getting Familiar with CBT and IPT

Good introductions to CBT and IPT: Cognitive-Behavior Therapy:

Persons, J.B., Davidson, J., & Tompkins, M.A. (2001). Essential components of cognitive-behavior therapy for depression. Washington, D.C.: APA

Interpersonal Psychotherapy: Weissman, M. W., & Markowitz, J. C. (2000).

Comprehensive guide to interpersonal psychotherapy. New York: Basic Books.

CBT: Clear Points of Contact

AABCT defines Cognitive-Behavioral Therapy as follows: CBT involves primarily the application of

principles derived from research in experimental and social psychology for the alleviation of human suffering and the enhancement of human functioning.

An Example of CBT’s Interest in Social Psychology

Review of Kruglanski’s “The Psychology of Closed Mindedness” in the April 2005 issue of the Behavior Therapist Emphasized the potential clinical

implications of both dispositional and experimentally manipulated closed mindedness. Example:

Link to Acceptance and Commitment Therapy

Common Factors Frank & Frank (1991) define common factors as

including: Setting designated as a place of help Therapeutic relationship

With an expert who is empathic, warm, supportive, and hopeful

A conceptual scheme or theory to explain the problem Compelling narrative may promote mastery and control

“Therapeutic rituals” Activities embedded in the explanation offered

May augment the persuasive power of the narrative Key reference:

Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of psychotherapy. Baltimore, MD: Johns Hopkins University Press.

Enhancing Common Factors A sophisticated analysis of common factors

from a social psychological perspective is lacking

There would seem to be considerable potential to enhance the efficacy of therapy through application of social psychological concepts Many of Brehm’s hypotheses remain viable but

are largely untested But such research must include clinical samples

Analog samples are insufficient

Predictors of Client Response to Treatment Patient uniformity myth (Kiesler, 1966)

Assumption that all patients with the same diagnosis are a homogeneous group

Search to identify client characteristics that predict treatment response has gone on for decades Thousands of studies have yielded surprisingly

little. But more sophisticated approaches may prove

fruitful Reference:

Petry et al. (2000). Stalking the elusive client variable in psychotherapy research. In C. R. Snyder & R. E. Ingram (Eds.), Handbook of psychological change. New York: Wiley.

Predictors of Therapist Efficacy Therapist uniformity myth (Kiesler, 1966)

Assumption that each and every therapist is an identical social stimulus for all patients.

Two types of therapist variables: Discrete characteristics

Ethnicity, age, gender, training, experience Relational characteristics

“Working Alliance” Working alliance = extent to which client and therapist

agree on goals, agree on tasks to attain those goals, and experience emotional bond

Research suggest the working alliance is most important “common factor” in treatment

Variables contributing to the quality of the Working Alliance: Use of self (e.g., self-disclosure) Empathy Genuineness

Reference: Yeber, E., & McClure, F. (2000). Therapist variables. In C. R. Snyder, & R. E. Ingram (Eds.), Handbook of

psychological change: Psychotherapy processes & practices for the 21st century (pp. 62-87). New Yorkl: Wiley.

Using Social Psychology to Better Understand Client X Therapist Interactions

Client reactance and approach to therapy: Dowd and colleagues (1991; 1994)

Have focused on individual differences in client reactance interacting with therapists approach to treatment

Shoham et al. (1996): treatment for insomnia High reactance clients responded better to

paradoxical interventions Low reactance clients responded better to

Progressive Relaxation Training

New Interventions for Treatment and Prevention

Advances in understanding of social-cognitive and interpersonal factors contributing to psychopathology may lead to innovative new interventions

Some examples: Training to normalize the anxious attentional

bias Training to enhance inhibition of socially

rejecting information in persons with low self-esteem (Dandeneau & Baldwin, 2004)

Attentional Retraining for GAD (Hazen, Vasey, & Schmidt, submitted)

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Attentional Retraining in Social Phobia (Amir et al., in progress)

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Extended attentional retraining (MacLeod et al.)Training induced latencies - New masked wordsTraining induced latencies - New masked words

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Extended attentional retraining (MacLeod et al.)Extended attentional retraining (MacLeod et al.)Trait anxiety scoresTrait anxiety scores - Both groups - Both groups

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Pre-TrainingPre-Training Post-TrainingPost-Training

An Alcohol Abuse Prevention Program With Connections to Social Psychology

Brief Alcohol Screening and Intervention for College Students (BASICS) Developed by Alan Marlatt and colleagues at

University of Washington Has been implemented at many universities including

OSU. My doctoral student, Meade Eggleston, is conducting

a dismantling study of BASICS for her dissertation

Brief Alcohol Screening and Intervention for College Students (BASICS):

1. Targets risk factors for heavy drinking identified in research on college drinking

2. Specifically, targets both social and cognitive determinants of drinking

3. Uses cognitive-behavioral techniques from Relapse Prevention Therapy

4. Uses Motivational Interviewing Strategies

BASICS Feedback: Drinking Norms

Purpose of giving feedback on perceived vs. actual drinking norms is to challenge the “false consensus” about heavy drinking

1. Give feedback on the student’s estimate of the frequency and quantity of drinking in college students compared to survey data (national and local, if possible)

2. Use CORE data, Monitoring the Future, or the Harvard College Alcohol Surveys for national norms

3. Whenever possible, use data from your campus as well

BASICS Feedback: Alcohol Expectancies

Aims of giving feedback about positive alcohol expectancies are:

1. To increase the student’s awareness of his or her implicit beliefs about alcohol, e.g. “liquid courage”

2. To challenge the myth that alcohol effects occur solely by physiology and thereby introduce psychological and social factors such as set and setting

3. To encourage the student to experiment with set and setting factors in order to get desired effects by drinking less or abstaining from alcohol altogether

BASICS Feedback: Perceived Risk

Aims of giving feedback about the student’s perceived risk for alcohol problems are:

1. To raise awareness of any discrepancies between perceived risk and actual negative consequences

2. To use motivational interviewing strategies to explore this discrepancy further and motivate change

3. To assist student’s with accurate perceived risk to begin considering ways to reduce their negative consequences and move into action stage of change

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BASICS Reduces Drinking-Related Harm

Improving EST Dissemination Efforts Rate of transfer of ESTs has been very slow

Example: ESTs for GAD, Panic Disorder, and Social Phobia are not

practiced widely despite strong evidence of efficacy (Goisman et al., 1999)

How can practitioners be more effectively persuaded to: Change their attitudes about ESTs?

Many practitioners are indifferent or hostile to the EST movement

Seek training in ESTs and implement them?

Reference: Stirman, S.W., Crits-Christoph, P., & DeRubeis, R.J. (2004). Achieving

successful dissemination of empirically supported psychotherapies: A synthesis of dissemination theory. Clinical Psychology: Science and Practice, 11, 343-359.

NIH Funding Priorities

NIH Funding Priorities

Subtext seems to be that NIMH will have a “disease specific” mission Thus, proposals apparently must focus

on disorders in clinical samples rather than on the behavior of non-clinical samples.

This clearly seems short-sighted Especially in light of inadequacies in the

DSM-IV classification system

What NIMH is Looking For

Basic research that: links behavior, brain, and experience is informed by and, in turn, informs our

understanding of: Etiology Our need for diagnostics Our quest for new interventions to prevent

or treat mental and behavioral disorders.

Bases for Evaluation of Grant Proposals

Relevance to the mission Traction for making rapid progress Innovation

But too much innovation may not be a good thing in actual practice Example:

The fate of our attentional retraining intervention grant proposal

NAMHC Report: Translating Behavioral Science into Action Emphasized translational research:

The large body of research on basic behavioral processes in normal populations and the powerful methodology built in such research now need to be extended to include clinical populations.

Provided 3 priority areas ripe for translation: How basic behavioral processes are altered in mental

illness and how these basic processes relate to neurobiological functioning

How mental illnesses and their interventions affect the abilities of individuals to function in diverse settings and roles

How social and other environmental contexts influence the etiology, prevention, treatment, and care of those suffering from mental disorders

Translational Funding Priority #1 Basic Behavioral Processes in Mental Illness

Understand how basic behavioral processes (e.g., cognition, emotion, motivation, development, personality, social interaction) are altered in mental illness

Understand how these processes relate to neurobiological functioning

Understand the implications of these alterations for: Etiology Diagnosis Course Prevention Treatment Rehabilitation

Translational Funding Priority #2

Functional Abilities in Mental Illness Understand how mental illnesses and

their treatments affect the abilities of individuals to function in diverse settings and roles Examples:

Carrying out personal, educational, family, and work responsibilities

Translational Funding Priority #3

Contextual Influences on Mental Illness and Its Care Understand how social or other environmental

contexts influence the etiology and prevention of mental illness and the treatment and care of those suffering from mental disorders

Context includes interactions among factors at the individual, family, sociocultural, and service-system or organizational levels.

NAMHC Report: Setting Priorities for the Basic Sciences of Brain and Behavior

Recommended strategies to sharpen the focus and impact of basic sciences research to better serve NIMH’s mission Basic brain and behavioral research should be

undertaken in the service of NIMH’s public health mission To reduce the burden of mental and behavioral

disorders (according to the Director, Dr. Insel) Basic research that integrates or translates across

levels of analysis (e.g., genetic to molecular) Emphasize research and training that is

interdisciplinary Invest in tools that will allow study of how complex

interpersonal, social, and cultural environments affect behavior at the integrative systems level

December 2004 Report of the Working Group to the Director

Gave 8 examples of how basic behavioral and social science findings have shaped understandings about health and illness.

Of these, at least 4 have clear connections to social psychology

Persuasion and Psychotherapy

The working group noted: Research shows that attitudes resulting

from strongly persuasive messages are less stable than attitudes based on experience

The working group suggests such research holds implications for the long-term efficacy of psychological interventions.

Stereotyping

The working group noted: Basic work on stereotypes, stereotyping

and cognitive processing have led to insights about how the medical care system provides unequal treatment to racial minorities even when there is little evidence of external racial bias.

Emotion

The working group noted: Basic research on emotion and affect has

provided a more differentiated and nuanced view of the ways that emotional functioning is altered in diseases such as schizophrenia, autism, and a range of neurological disorders.

Social Networks

The working group noted: Investigations on social networks and

social relationships form the basis for programs that enable families and groups to better assist individuals recovering from an illness.

Directions Most Feasible at OSU: Current Clinical Research Domains Anxiety (Vasey)

Experimental psychopathology Attentional retraining intervention

Depression (Strunk and Vasey) Experimental psychopathology Treatment research:

CBT process and outcome Expressed emotion (Fristad) Self-regulation (Thayer and Vasey) Narcissism and Aggression/Antisocial

Behavior/Psychopathy (Vasey) Health psychology (Andersen, Emery, Kiecolt-Glaser)

interfaces between social and clinical psychology past, current, and future directions michael w....

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