Providers Still Underestimating the Power of Social Context

We value goal-oriented work, and we assume any other approach would be much less effective. However, many of the benefits we find in life and work are unplanned, indirect, almost accidental. It is worth studying examples to find any patterns or principles. One lesson seems to be that there is often a social aspect to our unplanned gains. The power of our social context bears closer scrutiny.

A recurring example stands out from my career in managed behavioral healthcare. We worked with large group practices in the 1990s and directed a high volume of referrals to them to ensure predictable costs. It was a successful arrangement in terms of its desired goals, but a surprising secondary trend emerged. It involved the clinical outcomes being monitored for all outpatient care.

Every group practice achieved above-average clinical outcomes as compared to norms. This was true for dozens of groups across the country over many years. This robust finding was unintended and never well explained. We were left to speculate about it and never found any good structural or process explanation for this broad, major finding. Whatever else can be said, these groups were social entities.

A similar example relates to health habits. Research shows a person’s chance of becoming obese “increases by 57% if a close friend is obese, 40% if a sibling is obese, and 37% if a spouse is obese,” all of which is to say that it is “contagious,” as are the opposite, healthy eating and exercise. Significant people impact us in ways we do not plan or see, stemming from more than explicit communication.

What about goal-focused, deliberate practice? Many experts stress the importance of clinical practice guidelines and ensuring high fidelity to them by all therapists. Does fidelity pay? Extensive research analysis by Wampold and Imel suggests adherence to clinical guidelines is not correlated with therapy outcome. Instead, those therapists are better able to consistently form alliances with patients have better outcomes.

Some data even suggest that a deliberate focus on improving a client’s adherence to clinical protocols may have detrimental effects on outcome, while attention to the therapeutic alliance is beneficial. The alternatives here—thinking about clinical technique or thinking about the relationship—are quite clear, and data suggest we get greater unintended gains from focusing on the social element.

It is all a bit enigmatic. Group practices are social entities that facilitate interactions among clinicians. While not tested, this seems to be a factor in their performance. Relationships impact us in ways we see only in retrospect. We find this in how social ties can drive weight loss. Psychotherapy research suggests that, above all else, it is a powerful social process.

The idea of paying more attention to social context goes against the grain in many ways. It is often noted that our country embraces individualistic values, and our profession certainly shares this focus. While our field includes social workers and counselors trained in marriage and family issues, we still thrive on the diagnosis and treatment of individuals. It is one of the influences of the medical model.

The importance of social context is constantly being rediscovered. For example, after years of promoting wellness programs targeting individual behavior, employers identified a new strategy with their EAP leaders. Facilitating a “culture of health” within the workplace came to be seen as a necessary accompaniment to the individually focused wellness programs. Culture is a major focus today.

While these examples clearly emphasize the importance of social context, there is a reason beyond our individualism that we continually forget its role in life. We struggle to find goal-directed interventions that leverage this powerful dimension. It is fine to realize that others might influence us to lose weight in unspoken ways, and yet what is the wellness program we might create to harvest this dynamic?

Objections tend to surface at some point that such work is social engineering. People reject being manipulated. Yet many benevolent goals exist. For example, some workplaces set cafeteria pricing to influence employees to eat healthier foods. Social policies also drive healthy choices—as in the taxing and social constraints on smoking—but we find fewer social solutions to use in clinical practice.

Our understanding of how social context impacts our lives is probably rudimentary. Will this be a source for better health improvement strategies one day? Behavioral economics offer limited ways to “nudge” us for the better. Psychotherapy, our premier psychosocial solution, helps people one by one. We have bigger dreams. We want broad solutions requiring less personal grit and focus. Are they out there?

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.