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Interfaces Between Social and Clinical Psychology

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Title: 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 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)

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 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.

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
    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

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 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

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
    persons 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

20
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21
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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 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.

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 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

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

VIGILANCE
(ms)

plt.05
AVOIDANCE
Pre-Training
Post-Training
44
Extended attentional retraining (MacLeod et
al.) Trait anxiety scores - Both groups

Trait Anxiety Score

plt.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 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

48
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

49
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

50
(BASICS Research with n348)
BASICS Reduces Drinking-Related Harm
Control
Most significant impact found during first year
BASCIS
51
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.

52
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

54
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.

55
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

56
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

57
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

58
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

59
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.

60
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

61
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

62
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.

63
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.

64
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.

65
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.

66
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)
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