Interfaces Between Social and Clinical Psychology

1
Interfaces Between Social and Clinical Psychology

• Past, Current, and Future Directions
• Michael W. Vasey

2
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

3
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

4
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.

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

• Early pioneers (1961-1975)
• Emphasized social psychologys 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)

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

• 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

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

• Illustrative topics in Brehms 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
  clients emotional experiences.

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

• 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
  psychologys 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

9
History of the Social-Clinical Psychology
Interface (Kowalski Leary, 1999)

• Late 70s 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

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Current State of the Field

• A Brief and Selective Review

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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

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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

13
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.

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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 persons attributions
  for negative events
• Generalized hopelessness expectancies generate a
  specific subtype of depression
• Characterized by
• Increased interpersonal dependency
• Decreased self-esteem
• Apathy and lethargy

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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)

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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)

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State of Research on Social-Dysgenic Processes
Examples

• Social-Cognitive Processes
• 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.

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State of Research on Social-Dysgenic Processes
Examples

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

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State of Research on Social-Dysgenic Processes
Examples

• Social-Cognitive Processes
• 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

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State of Research on Social-Dysgenic Processes
Examples

• 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.

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State of Research on Social-Dysgenic Processes
Examples

• 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

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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.

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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.

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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.

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Some Potentially Fruitful Future Directions
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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 Strunks 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.

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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

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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

31
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

32
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.

33
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.

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An Example of CBTs Interest in Social Psychology

• Review of Kruglanskis 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

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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.

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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 Brehms hypotheses remain viable but are
  largely untested
• But such research must include clinical samples
• Analog samples are insufficient

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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.

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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.

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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

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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)

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Attentional Retraining for GAD (Hazen, Vasey,
Schmidt, submitted)
42
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 words

VIGILANCE
(ms)

plt.05
AVOIDANCE
Pre-Training
Post-Training
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Extended attentional retraining (MacLeod et
al.) Trait anxiety scores - Both groups

Trait Anxiety Score

plt.05
Pre-Training
Post-Training
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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

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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

47
BASICS Feedback Drinking Norms

• Purpose of giving feedback on perceived vs.
  actual drinking norms is to challenge the false
  consensus about heavy drinking
• Give feedback on the students estimate of the
  frequency and quantity of drinking in college
  students compared to survey data (national and
  local, if possible)
• Use CORE data, Monitoring the Future, or the
  Harvard College Alcohol Surveys for national
  norms
• Whenever possible, use data from your campus as
  well

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BASICS Feedback Alcohol Expectancies

• Aims of giving feedback about positive alcohol
  expectancies are
• To increase the students awareness of his or her
  implicit beliefs about alcohol, e.g. liquid
  courage
• To challenge the myth that alcohol effects occur
  solely by physiology and thereby introduce
  psychological and social factors such as set and
  setting
• 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

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BASICS Feedback Perceived Risk

• Aims of giving feedback about the students
  perceived risk for alcohol problems are
• To raise awareness of any discrepancies between
  perceived risk and actual negative consequences
• To use motivational interviewing strategies to
  explore this discrepancy further and motivate
  change
• To assist students 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 Research with n348)
BASICS Reduces Drinking-Related Harm
Control
Most significant impact found during first year
BASCIS
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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.

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NIH Funding Priorities
53
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

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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.

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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

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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

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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

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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

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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.

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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
  NIMHs mission
• Basic brain and behavioral research should be
  undertaken in the service of NIMHs 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

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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

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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.

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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.

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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.

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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.

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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)