Social Psychology in Clinical Practice: A Prerequisite for Effective Therapeutic Treatment
Part I: Overview of Submission
My target journal is the Psi Chi Journal. The length requirement is fewer than 35 pages and the citation style is APA. Submissions require a cover letter, cover page, a sponsor statement, and an original manuscript. Templates were provided by Psi Chi for the cover letter, cover page, and sponsor statement. They are included herein, prior to the manuscript. APA style requires an abstract and keywords.
Part II: Reflection on the Product
I did not have any significant changes to my original research question for this project, but I did go back and forth a few times about how to organize the thoughts being conveyed in the paper. I chose what seemed most appropriate, given the research I found and the sources being used.
Part III: Reflection on Process/Discussion of Method
My method of research inquiry began with forming a question that would address an unresolved problem and to which finding an answer would be interesting for an audience and for me. I wanted to find and dig into the existing discourse on integrating socio-psychological principles into clinical practice. I had begun to look at this topic in a previous class, and planned to extensively revise the short essay I had written to incorporate the current thoughts on the topic into one place, compare the arguments and stances and add my own thoughts to hopefully contribute to the conversation. It was helpful as I began my research to develop a list of keywords and to find the right forums to search. I gleaned some good insight on where to begin in the first few weeks of this course as well as from Dr. Buckingham, whom I interviewed for some help on research writing in the field of Psychology, specifically Social Psychology. Some tips I used were to plug my keywords into Google Scholar, take note of how many times each article had been cited and to look not only at the abstracts, but also the introduction, conclusion and the works cited within. This helped get a good start on some key sources I used in my final paper. Dr. Buckingham also named a few of her go-to journals, which I searched, as well. I also used the consortium library frequently. Prior to this assignment, I had only used the Academic Search Premier database, but found that there were many other options – some that were specific to psychology, such as PsycARTICLES and Psychology & Behavioral Sciences Collection, which proved to be very handy in locating relevant sources. I invested many hours of searching before I came across some of these tools, but I think of those hours as a head start on any future research I will need to do. I also found the source management tool to be very helpful, as well. It was a place to save the sources I thought I might be able to use, along with the list of relevant keywords, abstracts to easily refresh myself on the articles as I began to work on piecing them together into a cohesive conversation on my topic. I was also able to save any thoughts I had while reading the articles, so I was able to remember them when writing the paper. Having them in my source management tool also allowed me to easily search the abstracts and my own notes by keywords, since they were electronic rather than pen and paper, as I have normally done in the past. This saved lots of time in grouping them by schools of thought and in pulling pieces from the articles as they fit into the final paper. I feel like this revision project has greatly improved my research writing skills, although it still feels quite daunting to think of starting a whole new research inquiry from the beginning and pull it all together into a cohesive argument.
Abstract
This paper reviews the literature on the nuances of social psychological theories as they pertain to the practice of clinical psychology. Although the integration of social psychological theories into the clinical psychological setting has been grossly overlooked for many years, discourse on the idea has been available, albeit sparse, for quite some time. The literature on this integration has begun to increase in recent years, as shown in the articles discussed here. The following includes research from peer-reviewed articles which serve as a sample of the discourse on the idea of integration between these two subfields of psychology. Socio-psychological theories are explained as they arise and how they relate to the interaction between therapist and patient. I will also introduce some research as it relates to the medical setting. Research is included on why the subfields remain unintegrated given the current discourse as well as recommendations on how to facilitate this integration and further inquiries which should be researched going forward.
Keywords: clinical psychology, socio-psychology, social psychology, attribution theory, therapeutic effectiveness, embodied cognition, transference, thinking styles, implicit, explicit
Social Psychology in Clinical Practice: A Prerequisite for Therapeutic Effectiveness
Social psychology studies the ways in which people think about, influence, and relate to one another, whereas clinical psychology is the assessment and treatment of mental, emotional, and behavioral disorders. In clinical practice, psychologists generally tend to lean toward the medical model of diagnosing and treating an illness, while disregarding the socio-psychological research on how interactions between people affect cognitive processes, mental, and emotional health. This can be detrimental to patient-therapist relations and can lead to misdiagnosis and ineffective or even harmful treatment therapies. The idea of integrating social psychological theories into the clinical setting has been grossly overlooked in the past, with only a few sporadic references. In more recent years, the literature has begun to gain momentum, as shown in the articles discussed herein. This study focuses on how social psychological theories affect the clinical practice of psychology, both from the clinician and the patient perspective and highlights the importance of clinicians remaining mindful that they, too, are predisposed to the ways people related to one another.
Thinking Styles of the Clinician
In considering socio-psychological research as it applies to the clinical setting, discourse has been limited until fairly recently on how clinicians are affected in their evaluation and diagnosis. In an effort to add to the discourse, Aarts, Witteman, Souren, and Egger (2012) studied these clinical judgements in the context of individual thinking styles. They noted that much research has been done on how a therapist’s experience level affects their clinical judgements but hypothesized that individual thinking styles play a big role, as well. Clinical psychologists often refer to the Diagnostic and Statistical Manual (DSM) for specific criteria in diagnosing psychological disorders, but many experienced clinicians employ intuition or are apt to compare patients to previous cases or prototypes and then construct causal relationships between those symptoms and a diagnosis (Aarts et al., 2012). In their research, Aarts et al. (2012) assessed how these differing thinking styles affect the accuracy of clinical diagnostics. They used the Rational and Experiential Inventory (REI) survey to assess thinking styles before giving 25 participant psychologists two test cases for which they were to choose two out of twenty diagnoses from a drop down. Participants were allowed to consult the DSM and given a time limit in which to select the diagnoses. Their findings indicated that experience level did not significantly influence thinking styles nor the accuracy of the diagnoses, but rather, significant associations were found between thinking styles and accuracy – the higher they scored in conscious, rational thinking, the lower they scored in diagnostic accuracy (Aarts et al., 2012). Although this experiment included a very small sample size of therapists and was narrow in scope, it is indicative that clinical psychologists are persuaded by their thinking styles in their judgments and diagnoses, which suggests more research is needed to investigate other socio- psychological persuasions of therapists in their clinical practices.
When considering thinking styles, social psychologists often distinguish between explicit versus implicit processing. Boysen (2009) reviewed biases in clinical psychology, including explicit bias, which is conscious and measured by self-report, and implicit bias, which is outside of conscious awareness, thus measurement is more indirect and difficult. Some people show a tendency toward one or the other, as reflected in their judgments and decisions, often based on their self-concept of ability or their personality traits. In terms of their influence in most research on counseling, there had not yet been a distinction made between implicit and explicit biases according to Boysen (2009). His review of the discourse on the topic yielded evidence that explicit bias is generally not present among counselors, while implicit bias is common. Although Boysen (2009) admitted his research was not extensive, it did indicate that measuring for explicit bias exclusively does not give a full picture of therapists’ attitudes and biases. Lewis (2009) noted that Freud, as far back as 1910, cautioned therapists that treatments could be tainted by these implicit biases. It is interesting, then, that only recently has the discourse on the idea of integrating socio-psychological theories into clinical practice began to pick up momentum.
Additional research supports the idea that there are many specific socio-psychological manifestations to which we are all susceptible, including clinicians. Chen, Froehle & Morran (1997) discussed these specific cognitive biases as they pertain to therapists, particularly attribution theory. Often in their assessments, therapists attribute problems to a client’s temperament, attitudes and traits and fully disregard the role the client’s circumstances and environment might play. Since counselors have more access to information about the patient than to their circumstances, they are more given to dispositional attributions. Chen et al. (1997) proposed, “This tendency for counselors to infer personal defects and to neglect contextual forces invites inferential errors” (p. 74). Clinical psychologists are also influenced by the medical model of illness residing within the patient, which directs the focus to the patient needing to be fixed without considering the effects of the environment (Chen et al., 1997). Social norms add to this attribution error by dictating that a person must adapt to his environment rather than the environment being changed. Chen et al. (1997) proposed systematic research is needed to explore ways of preventing these damaging biases, beginning with counselors in training. They hypothesized that training counselors on attribution theory and empathetic perspective would allow trainees to avoid the pitfalls of biases and view the situation as a whole from the perspective of the client. Their study supported their hypothesis, in effect making a compelling argument that counselor trainees can and should be trained on social psychological biases and on how to avoid them in order to reverse these fallacies (Chen, 1997). This aligns with Witken’s (1982) earlier recommendation in which he explained that every interaction a therapist has with a patient involves a series of cognitive activities, such as gathering data, retrieving information from memory, forming hypotheses and judgments and making decisions, noting that there is plenty of room for error amidst so much cognitive activity. He cited the illusory correlation theory of sociological psychology as one such error, which suggests that once a therapist has noticed a correlation between two things, such as a situational occurrence and a patient’s behavior, they are likely to overestimate the frequency of the two occurring together (1982). Another of these cognitive errors noted by Witken (1982) is the perseverance theory, the idea that often when an error in judgment is made, it becomes resistant to new or corrected information. Like Chen et al., Witken (1982) also cited the attribution theory as another error that contributes to the fallacies in a therapist’s cognitive processes. To begin with, he explains the actor-observer difference in assigning causality. This theory maintains that the actor or subject of a situation – being aware of the surrounding circumstances – is more likely to attribute their own behavior in any given situation, at least in part, to the circumstances of their environment, while an outside observer is more likely to assign the cause of a person’s behavior to their character, regardless of the severity of the actor’s situation (Witken, 1982). Introspective awareness, or the ability of the therapist to evaluate their own cognitive processes in making judgments, could also shed light on personal biases (Witken, 1982). The difficulty is that these cognitive processes are automatic and hard for an individual – even a therapist – to access without proper training and attention, compounded by the fact that therapists seem to overlook the importance and application of these theories to their clinical work.
Lewis (2009) also agreed with the discourse on attribution theory and that therapists must be mindful to consider a patient’s environment and situation before attributing reactions or responses to the patient’s disposition (2009). Lewis reiterated that attribution as well as countertransference biases are present in every therapy session, whether or not they are acknowledged by the counselor (2009). But the idea that all counselors would be trained to identify and work on their own reactions is an unreasonable expectation since the concept is not widely accepted in the field (Lewis, 2009). Transference is the projection of the client’s feelings onto the therapist, while countertransference refers to a therapist’s unconscious response to the client’s transference. Lewis (2009) asserted that, by the 1950’s, the literature on countertransference reactions described the socio-psychological phenomenon as “inevitable, universal, ubiquitous and a presumably normal feature of every analysis” (p. 109), to include both conscious and unconscious responses. As early as 1962, Alexander Thomas, M.D. wrote an article to highlight the effects of socio-psychological phenomena, particularly pseudo- transference reaction, as it relates to a therapist’s diagnosis and therapeutic process. While transference reaction refers to the patient’s abnormal and unwarranted reaction to a therapist’s constructive criticism as a result of a vulnerability to criticism, pseudo-transference looks like transference but is the response to criticism based on the implicit behavior or attitudes of the therapist, usually biased or stereotyped (Thomas, 1962). He noted that attempts to minimize this phenomenon should include the therapist’s self-psychoanalysis to eliminate the unconscious biases and to maintain an objective therapeutic forum in which the counselor remains detached (Thomas, 1962). He hoped to draw attention to the potential negative impact of a therapist’s biases as they encourage pseudo-transference, and he was particularly concerned with the fact that therapists freely discussing their stereotypical options with cohorts minimizes the idea that their biases are “irrational and inappropriate” (Thomas, 2009, p. 896). The patient is then likely to easily detect these attitudes “as he has experienced them and suffered from them over and over again in the outside world” (Thomas, 2009, p. 896). It is important to note, as an aside, that racism was an important societal issue at the time this article was written. The article explained that the therapist might unknowingly display these biased attitudes and the patient might respond defensively, unaware of the source of his own defensiveness. The therapist detects the hostility and assigns a diagnosis of transference, which seems reasonable to the patient, who is unaware of the source of his own anger. Encountering the same scenario in the outside world with the same reaction, the patient is even more incorrectly convinced that the diagnosis must be accurate. Thomas (1962) noted that a review of literature showed therapists are not immune to the stereotyped attitudes prevalent in culture. Like Lewis (2009), Thomas (1962) also made mention that much earlier in history, Freud conveyed these types of biases, particularly against women, in his own work. He shared examples of biases against women and African Americans among the current literature of his time and asserted, “Over the years I have seen a number of patients who have been exposed to derogatory, culturally determined, stereotyped attitudes in the psychotherapeutic situation with unfavorable results” (Thomas, 1962, p. 898). Thomas (1962) asserted that the therapist must remain aware of the potential for the expression of their own culturally influenced stereotypes in order to avoid drawing an antagonistic response from the patient. We must, then, think not only about how the therapist’s thinking styles and biases color their own evaluation of the patient-therapist interaction, but also how their biases affect the patient’s experience.
The Patient’s Perceptions
The effects of socio-psychological concepts as they apply to the therapist’s cognitive processes within the clinical setting are certainly mirrored in the way a patient perceives and responds to the clinical interaction with the therapist. A good example is the socio-psychological theory of self-fulfilling prophecy which, in the patient-therapist scenario, alludes to the clinician’s incorrect inferences about the patient’s character or other intrinsic qualities often leading the patient to begin to conform and exhibit those traits. Perhaps this reciprocation of incorrect cognitive processing is perpetuated then by the therapist incorrectly detecting other conditions which corroborate the diagnosis, such that these biases contribute to both the development and persistence of incorrect diagnoses. While the patient is reacting to the therapist’s display of automatic cognitive processing, the patient is also experiencing separate automatic, uncontrollable thought processes of their own. In their article, Folk, Disabato, Goodman, Carter, DiMauro, and Riskind (2017) supported the idea that integrating concepts from social psychology not only improves the clinician’s understanding of the patient’s emotional, cognitive and behavioral problems, but also increases therapeutic effectiveness for the patient. According to Folk et al. (2017), socio-psychological perspectives are key to understanding how a patient manifests psychological distress due to the way they interpret and react to their situation. The authors argued the interpretation is far more relevant than the objective situation and they noted individuals have “habitual cognition styles” (Folk et al., 2017, p. 408), which govern how they interpret situations. An example would be a patient with a propensity toward attributing others’ behavior to hostile intentions or a patient being particularly given to attributing negative outcomes to their own unchangeable defects. Therapeutic effectiveness is also moderated by other individual differences between patients, as noted by Folk et al. (2017), such as self-concept, interpersonal dependency, self-consciousness and attributional style. In their article, they explain how recent developments in socio-psychological concepts including self-identity, transference and embodied cognition have clear applications to clinical practice (Folk 2017). Beliefs about the self, for example, have been shown to affect a patient’s adjustment as they are affected by the socio-psychological concepts of self-efficacy (the belief in one’s own capabilities) and locus of control (the extent to which one believes either they have control over the events in their life or that outcomes are governed by external forces beyond their control), and these theories have been implemented in a few therapeutic methods (Folk et al., 2017). The extent to which one believes they can change (modifiability of the self) determines how well a patient handles transition and whether they are open to learning or willing to confront and persevere through challenges. In school settings, interventions that encourage malleable self-concepts return favorable results including higher GPAs and increased enjoyment of academics (Folk et al., 2017). By combining this theory with cognitive behavioral therapy in a clinical setting, Folk et al. (2017) suggested a clinician has the potential to address a patient’s ability to overcome alcoholism, for example, by first demonstrating the patient’s control over a semi-challenging behavior. Reflecting on the locus of control and the malleability of the patient’s cognition and behavior, they are then able to apply these concepts to more severe issues. Folk et al. (2017) also suggested that relational schemas developed during past relationships are stored in memory and projected onto new relationships or even strangers through the transference context. Transference can describe the socio-psychological theory that a memory or interpretation of a past relationship is applied to other people or relationships that seem similar. Contact with someone who bears resemblance to a past contact causes an automatic inference of similar attributes, which might then trigger one to assume the prior self-concept they held during that relationship, including their feelings of self-worth or attractiveness (Folk et al., 2017). Thus activation of relational schemas in transference is linked to tendencies toward self-criticism and self-regulation. Therapists should be mindful in the clinical setting of research findings on transference and consider whether the patient might be affected by this socio-psychological phenomenon. In addition to traditional data collected from patients, therapists should consider evaluating the patient’s past relationships, including names and physical characteristics, considering how the patient might be perceiving current relationships to be a reflection of previous relationships (Folk et al., 2017). Embodied cognition is another area of socio- psychological research of which therapists should be mindful in the clinical setting, as it colors the patient’s experience. Research on this concept shows that, in addition to the mind influencing the body’s actions, so does the body impact the mind in cognition and emotion (Folk et al. 2017). Studies presented by Folk et al. (2017) on facial expressions, for example, have shown that smiling increases positivity while those with impaired motor function in the facial muscles responsible for smiling report more severe depression than those with other facial impairments. Cognition is also altered by posture, head movement and sensorimotor experiences, according to Folk et. al (2017), such that a slumped posture lends a patient toward feelings of helplessness more than an erect posture; nodding versus shaking of the head leads to more or less confidence, respectively, in a person’s argument; and even the weight of a clipboard can lead a patient to interpret a situation as more or less severe. In applying these research findings to clinical practice, therapists might suggest to a client struggling with social anxiety to assume a more erect posture while in social situations or advise a patient working to resolve an incorrect, automatic bias to consider a more appropriate thought while nodding the head in affirmation. It is worth noting that each of these concepts conversely applies to clinicians, as well, such that the weight of their clipboard or the expressions they hold on their own faces could alter how severe they perceive a client’s issues to be.
Impediments to Integration
Since research on the argument for incorporating socio-psychological concepts into the clinical setting has continued to gain momentum in recent years and is more convincing than ever, it is necessary to discuss why the integration has yet to occur, along with some of the fallacies behind the reasons for the continued separation. Besides the growing discourse still being somewhat limited, there are a few other reasons for the exclusion of these concepts in clinical practice discussed by the authors cited herein. One impediment to such integration noted in the work by Folk et al. (2017) is the separation of the literature on social psychology and the clinical practice, such that clinical therapists rarely consult socio-psychological research findings in their practical work. According to Folk et al. (2017), this is because clinicians typically prefer the autonomy of charting their own path of originality in effective treatments and influence in their field. Additionally, the literature on socio-psychological theories often fails to include the clinical application, so clinicians often overlook the relevance to their practice (Folk et al., 2017). As noted by Chen et al. (1997), clinicians are also influenced more by the medical model than by the research on psychology, such that they are often looking for a disease or illness within the patient and rely more on research in those areas versus socio-psychological findings. This type of thinking is flawed and dangerous as demonstrated in the study by Teal, Gill, Green, and Crandall (2012). The researchers studied this topic as it applies to an actual medical practice, focusing on preferential treatment, treatment decisions and the clinician-patient relationship in the medical setting (Teal et al., 2012). Their findings suggested unconscious cognitive biases of physicians are sometimes the cause of disparate care of minorities and errors in the medical field to include decisions about urgency, aggressiveness of treatment, pain management and transplants (Teal et al., 2012). In light of these disturbing findings, it is surprising that there are still varied stances among researchers and educators on whether and how these unconscious biases should be addressed. Some believe clinical students should be taught to remain deliberately cognizant of these automatic thought processes in order to avoid them, some argue this is unrealistic and that the unconscious thoughts are useful, while others advocate for a dual-process model (Teal et al., 2012). Whether a researcher advocates for integration or against it, agreement is widespread that socio-psychological issues as they pertain to any clinical practice setting are difficult to address, which continues to be a roadblock to the integration of the two fields of research.
Methods for Integration
The authors cited herein have suggested several methods by which the integration could occur if the community of psychological clinicians could be convinced of the dire need for social psychological research findings to be incorporated into clinical practice. Folk et al. (2017) agreed with others who have argued for formal integration of social psychology into the clinical setting as an enhancement to many standard clinical treatments currently in use. They suggested some specific ways therapists could incorporate socio-psychological theories into practice, including the earlier example of a patient having a fixed self-theory causing them to believe they are incapable of improvement or change. The therapist could provide a semi-challenging task upon which the patient would gradually improve, instilling a sense of self-malleability, restoring locus of control, and preparing the patient to overcome more difficult challenges (Folk et al, 2017). Another suggestion for integrating social psychological concepts into a cognitive behavioral therapy treatment plan offered by Folk et al (2017) is that therapists need to stay engaged in the social psychology field of research and be mindful of findings to determine whether the patient might be affected by these socio-psychological phenomena. In doing so, therapists might then consider the patient’s environment and circumstances to avoid cognitive fallacies associated with the attribution theory. They might be more likely to consider past relationships, including names and physical characteristics, evaluating how the patient might be to be a reflection of previous relationships, avoiding fallacies of the transference theory. Others have offered general concepts for integration, including Lewis (2009), who suggested that all students of clinical psychology should be trained to investigate and understand their own personal biases and preconceptions and should explore how they might apply to each patient- counselor interaction. As Teal et al. (2012) noted, some researchers and educators believe clinical students should be taught to remain deliberately cognizant of these automatic thought processes and work to avoid them. Teal et al. (2012) offered their own position on the issue from a medical standpoint, that the automatic cognitive processes cannot be avoided, but can be managed and the impact reduced, which they claim is consistent with how psychologists function
perceiving current relationships in the clinical setting. They proposed a model by which learners can identify, accept and learn to mitigate the influence of the biases on their treatment of patients (Teal et al., 2012). Current curricula include cultural competencies to train on how to care for groups with widespread, generalized stereotypes are assigned, such as African Americans being untrusting of medical treatment. Instead, students should be taught to recognize these characteristics among individual patients (Teal et al., 2012). This would discourage reliance on stereotypes. Likewise, learning about these types of issues as being cross-cultural issues rather than being associated with a particular group will allow learners to more easily recognize how their own biases might frame how they view patients (Teal et al., 2012). In addition, Teal et al. (2012) found that the validity of the Implicit Association Test (IAT), which is a computer-based assessment of automatic biases, is supported in most of the literature they reviewed. Doctors have found it useful in assessing whether unconscious racial biases match or exceed self-reported biases. The writers found only one report of the IAT being used in medical education (Teal et al., 2012). Other methods noted which are being used to raise awareness of unconscious bias among students are small group discussions, writing activities that promote reflection, imagery, standardized questions, and guided debriefs (Teal et al., 2012). Some medical educators are creating opportunities for students to encounter their own biases through cross-cultural simulations which allow for students to assess and treat patients with many different combinations of characteristics, and then debrief on the experience. This is expected to promote awareness and management of unconscious biases and foster confidence in the students about their ability to recognize and abate biases and successfully interact with and treat patients different from themselves, thereby further reducing biases (Teal et al., 2012). Mindfulness training (Teal et al., 2012) and empathy training (Chen et al., (1997) for prospective therapists are also suggested, as it teaches students to ask questions of themselves, such as what might be informing their decision, how they are feeling, what assumptions they are making, as well as what the patient might be thinking and what role their environment and past relationships might play in the issue at hand. This is certainly not a comprehensive list of methods for incorporating socio- psychological concepts into clinical practice, but it offers a few potential starting points.
Conclusion
In light of the growing research on social psychological theories and the way they affect all human interactions, particularly in the therapist-patient context, there is a compelling call for the integration of this field of research to be incorporated as a necessary addition to the research base regularly used by clinicians in practice. Without this integration, the practice of clinical psychology remains at risk of misdiagnosing and providing ineffective or damaging therapeutic treatment plans based on inadvertent cognitive interference for the therapist as well as the patient. Ultimately, clinicians must remain mindful that they are predisposed to the ways in which humans think about, influence and relate to one another, and that the clinical setting is no exception. Moreover, the literature on the integration of these two fields of research largely agrees that this is not an easy task. While there are a few recommendations cited within, more research is in order to determine an effective way to ensure therapists and patients, alike, have an individualized, objective experience in the clinical setting, which is free of preconceptions, automatic and inadvertent biases, and that focuses strictly on the mental health of patients as unique individuals in the context of their own circumstances, environments and relationships. Longitudinal studies are recommended to gauge efficacy upon integration of these two subfields of psychology. Given Teal et al.’s (2012) findings on inadvertent cognitive fallacies of clinicians in the medical setting - and the dangerous implications for patients - additional research specific to social psychology in the medical field is also in order.
References
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COURTNEY BARCH is a Junior pursuing a Baccalaureate degree in English with a minor in Psychology. This piece was selected by Professor Jacqueline Cason.