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.

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

6. 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

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

8. 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 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

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

10. Current State of the Field A Brief and Selective Review

11. 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

12. 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.

14. 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

15. 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)

16. 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)

17. 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.

18. 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 person’s catastrophic beliefs about the dangers of a panic attack from disconfirmation.

19. 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

22. 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.

23. 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

24. 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.

25. 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.

26. 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.

27. Some Potentially Fruitful Future Directions

28. 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.

29. 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

30. 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.

34. 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

35. 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.

36. 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

37. 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.

38. 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.

39. 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

40. 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)

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

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

43. Control Training Avoid Threat Extended attentional retraining (MacLeod et al.) Training induced latencies - New masked words VIGILANCE (ms) p<.05 AVOIDANCE Pre-Training Post-Training

44. Avoid Threat Control Training Extended attentional retraining (MacLeod et al.) Trait anxiety scores - Both groups Trait Anxiety Score p<.05 Pre-Training Post-Training

45. 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

46. Brief Alcohol Screening and Intervention for College Students (BASICS): • Targets risk factors for heavy drinking identified in research on college drinking • Specifically, targets both social and cognitive determinants of drinking • Uses cognitive-behavioral techniques from Relapse Prevention Therapy • 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 student’s 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

48. BASICS Feedback: Alcohol Expectancies Aims of giving feedback about positive alcohol expectancies are: • To increase the student’s 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

49. BASICS Feedback: Perceived Risk Aims of giving feedback about the student’s 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 student’s with accurate perceived risk to begin considering ways to reduce their negative consequences and move into action stage of change

50. BASICS Reduces Drinking-Related Harm (BASICS Research with n=348) Control Most significant impact found during first year BASCIS