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Treatment of Psychological
Disorders
OUTLINE OF RESOURCES
I. Introducing Treatment of Psychological Disorders
Introductory Exercise: Fact or Falsehood? (p. 3) Lecture/Discussion Topic: The Availability and Adequacy
of Treatment (p. 4) Classroom Exercises: Therapist Role-Playing (p. 3)
Attitudes Toward Seeking Professional Psychological Help (p. 3)
Videos: Psychology: The Human Experience, Module 40: Problems in Living* Digital Media Archive:
Psychology, 1st ed., Video Clips 35 and 36: Treatment of Drug Addiction and Early Treatment of Mental
Disorders*
Psychology Video Tool Kit: Early Treatment of Mental Disorders* Outpatient Commitment: Forcing
Persons Into Mental Health Treatment*
II. The Psychological Therapies
Feature Film: Ordinary People and Psychotherapy (p. 4)
A. Psychoanalysis
Lecture/Discussion Topic: Good Candidates for Psychoanalysis (p. 5)
B. Humanistic Therapies
Lecture/Discussion Topic: Computer-Assisted Psychotherapy (p. 5)
Classroom Exercises: Understanding Empathy (p. 7) Role-Playing to Demonstrate Client-Centered
Therapy (p. 7) The Self-Concealment Scale (p. 8) The Imposter Phenomenon (p. 8)
Student Project: Dibs and Play Therapy (p. 8) PsychSim 5: Computer Therapist (p. 5)
C. Behavior Therapies
Lecture/Discussion Topics: Virtual Iraq (p. 10) Exposure Therapy—Improving Its Effectiveness (p. 11)
Therapy and Totalitarian Control (p. 11)
Classroom Exercises: Using Systematic Desensitization to Treat Eraser Phobia (p. 9) Modeling (p. 11)
Assessing Assertiveness (p. 12)
Student Projects: Practicing Systematic Desensitization (p. 10) Modifying an Existing Behavior (p. 12)
ActivePsych: Digital Media Archive, 2nd ed.: Therapy in the Real World: The Use of Real-Life Exposure to
Treat Phobias*
*Video, ActivePsych, and Psychology Video Tool Kit titles followed by an asterisk are not repeated within
the core resource unit. They are listed, with running times, in the Preface of these resources and
described in detail in their Faculty Guides, which are available at www.worthpublishers.com/mediaroom.
Videos: The Mind, 2nd ed., Module 30: Treating Drug Addiction: A Behavioral Approach* Scientific
American Frontiers, 2nd ed., Segment 31: Virtual Fear* Feature Film: Harry Potter and the Prisoner of
Azkaban (p. 9)
D. Cognitive Therapies
Lecture/Discussion Topics: Strategies to Correct One’s Thinking (p. 13)
Overcoming the Fear of Public Speaking (p. 14) Classroom Exercise: Frequency of Self-Reinforcement
Questionnaire (p. 14) Student Project: Mood-Memory Repair (p. 15) Psychology Video Tool Kit: Treating
OCD: Exposure and Response Prevention*
E. Group and Family Therapies
Psychology Video Tool Kit: City of Gheel: Community Mental Health at Its Best*
III. Evaluating Psychotherapies
A. Is Psychotherapy Effective?
Lecture/Discussion Topics: The Consumer Reports Study (p. 16) Fringe Medicine (p. 17) Regression
Toward the Mean (p. 17) Thinking Errors and Clinical Judgment (p. 19) Therapy and the Nature of the
Problem (p. 19)
Classroon Exercise: Regression Toward the Mean and Aspiration Level (p. 18) Video: The Mind, 2nd ed.,
Module 3: The Placebo Effect: Mind-Body Relationship* PsychSim 5: Mystery Therapist (p. 16)
B. The Relative Effectiveness of Different Therapies
Lecture/Discussion Topics: Writing About Emotional Experiences as Therapy (p. 20) Psychological
Treatments Versus Psychotherapy (p. 21) Video: Psychology: The Human Experience, Module 41:
Empirically Validated Therapies*
C. Evaluating Alternative Therapies
Lecture/Discussion Topics: Pets in Therapy (p. 21) Trepanation (p. 22) Autobiographies (p. 22)
Psychology Video Tool Kit: Dealing With Panic*
D. Commonalities Among Psychotherapies
Lecture/Discussion Topic: Evaluating Self-Help Resources (p. 23)
E. Culture and Values in Psychotherapy
Lecture/Discussion Topic: Mental Health Values of Professional Therapists (p. 24) Student Project:
Applying the Major Therapies (p. 25) (Useful as a conclusion to section III) Psychology Video Tool Kit:
Mentally Ill Chemical Abusers: A Community Problem*
When Treatment Leads to Execution: Mental Health and the Law*
IV. The Biomedical Therapies
A. Drug Therapies
Lecture/Discussion Topics: SSRI Antidepressants (p. 25) Cosmetic Psychopharmacology (p. 25) A Pill for
Stage Fright (Anxiety) (p. 26)
ActivePsych: Digital Media Archive, 2nd ed.: The Therapeutic Effect of Antipsychotic Drugs*
Schizophrenia: New Definitions, New Therapies * Undesired Effects of Conventional Antipsychotic Drugs*
Videos: The Mind, 2nd ed., Module 33: Mood Disorders: Medication and Talk Therapy* The Brain, 2nd
ed., Module 28: Schizophrenia: Pharmacological Treatment* Digital Media Archive: Psychology, 1st ed.,
Video Clip 34: Schizophrenia*
B.
Brain Stimulation
Lecture/Discussion Topic: Electroconvulsive Therapy (p. 27)
Videos: The Mind, 2nd ed., Module 34: Treating Depression: Electroconvulsive Therapy (ECT)* Digital
Media Archive: Psychology, 1st ed., Video Clip 37: Electroconvulsive Therapy*
C.
Psychosurgery
Lecture/Discussion Topic: Cingulotomy (p. 27)
D.
Therapeutic Life-Style Change
Lecture/Discussion Topic: Therapeutic Life-Style Change (p. 28)
V. Preventing Psychological Disorders Lecture/Discussion Topics: Positive Psychotherapy (p. 29)
From a Disease Focus to a Wellness Model (p. 29) Principles of Effective Prevention Programs (p. 30)
Classroom Exercise: The Personal Growth Initiative Scale (PGIS) (p. 30)
UNIT OUTLINE
I.
Introducing Treatment of Psychological Disorders (pp. 605–606)
Introductory Exercise: Fact or Falsehood?
The correct answers to Handout 13–1, as shown below, can be confirmed on the listed text pages.
1
2
3
4
5
F (p. 606) 6. F (pp. 625–626)
F (p. 610) 7. F (p. 626)
F (p. 613) 8. T (p. 628)
F (pp. 620–621) 9. T (p. 632)
T (p. 625) 10. F (p. 633)
Classroom Exercise: Therapist Role-Playing
Timothy Osberg suggests a role-playing activity to introduce the topic of therapy. He uses it primarily to
demonstrate how our underlying theories about psycho-logical disorders guide the therapeutic methods
we use. Although Osberg designed the exercise primarily for abnormal and clinical psychology courses, it
also seems appropriate for introductory psychology students, particularly if they have just studied Unit 12
on psychological disorders.
As an introduction to Unit 13, read the following to your students:
As a preface to our discussion of the various theoretical approaches to psychotherapy, I have a brief exercise
wherein I’d like each of you to assume the role of therapist. Please sit back and imagine that a good friend of
yours has approached you about a problem he or she has developed recently. This friend describes several
symptoms, including increased feelings of depression, crying spells, loss of interest in usual activities, and
changes in sleep and eating patterns. Let’s assume you have asked enough questions to allow you to conclude
that this per-son is clinically depressed. Your task is to assume the role of therapist and develop some possible
interventions. Spend a few minutes reflecting and I will ask members of the class to volunteer suggestions.
Please write two or three ideas on a sheet of paper.
After students have been given 4 to 5 minutes to respond, ask for volunteers to share their suggested
interventions and record them on the chalkboard. Osberg notes that students’ recommendations often
include having the person increase the number of his or her activities or involvements, increase exercise,
expand social networks, attend self-help or other group therapy sessions, begin journaling, and seek
medication. After obtaining 8 to 10 suggestions, note how they reflect students’ underlying theories of
depression. Osberg explains that students tend to favor behavioral or cognitive-behavioral strategies.
However, as you review the various therapies discussed in the text, remind the class of the extent to
which their suggestions reflected each approach.
Osberg, T. (1996, August). Students as therapists: An activity for abnormal and clinical psychology courses.
Paper presented at the Annual Convention of the American Psychological Association, Toronto.
Classroom Exercise: Attitudes Toward Seeking Professional Psychological Help
Psychologists Edward Fischer and Amerigo Farina have developed a scale to assess respondents’
attitudes toward seeking psychological help. In introducing this unit, you might have students complete
the scale (see Handout 13–2). To score, students first need to reverse the numbers they placed before
items 2, 4, 8, 9, and 10 (0 = 3, 1 = 2, 2 = 1, 3 = 0), and then add the numbers in front of all 10 items. Total
scores can range from 0 to 30, with higher scores reflecting a more favorable attitude toward seeking
professional psychological help. Fischer and Farina report mean scores of 19.08 and
15.46 for female and male undergraduates, respectively.
You can use the scale to initiate a class discussion of possible obstacles to seeking help. Is it more
difficult for people to seek help for psychological problems than for medical problems? What accounts for
gender differ-ences in attitudes toward seeking professional psycho-logical help? In addition to gender
differences, the authors report that within certain ethnic groups, those who hold strong cultural affiliations
are less inclined to favor seeking professional help than are those who identify with the broader American
culture. There is also a tendency for psychology and social science majors to be more favorably inclined
toward seeking professional help. Among the major academic concen-trations, those with business
concentrations were least in favor of it. What might account for these individual differences?
A 2004 American Psychological Association (APA) poll reported that nearly half of Americans
have had someone in their household seek mental health treat-ment at some time. Most (81 percent)
continue to per-ceive cost and lack of insurance coverage (87 percent) as barriers to getting treatment.
An increasing number of Americans (85 percent) believe that health insurance should cover mental health
services, up from 79 percent when the same question was asked in December 2000. Poll results also
showed that only 30 percent of Americans say that they would be concerned about other people finding
out that they had seen a mental health professional, and only 20 percent say that stigma is a very
important reason not to seek help. Nearly half (47 percent) say that the stigma surrounding mental health
services has decreased in recent years and that the media gets the most credit for that (35 percent),
although society in general (25 percent) seems to be more accepting as well.
American Psychological Association. (2004, May 13). APA poll: Most Americans have sought mental health
treatment but cost, insurance still barriers. APA Online. Retrieved February 14, 2009 from www.apa.org/
releases/practicepoll_04. html.
Fischer, E. H., & Farina, A. (1995). Attitudes toward seeking professional psychological help: A shortened form
and considerations for research. Journal of College Student Development, 36, 368–373.
Lecture/Discussion Topic: The Availability and Adequacy of Treatment
How many people who need therapy actually receive it? In Unit 12, we reported Ronald Kessler and his
colleagues’ survey of the prevalence of psychological disorder. In their assessment of a representative
sample of 9282 Americans, they also sought to determine whether people who suffer psychological disorder
are receiving adequate treatment. Their study suggested that only a third of patients receive adequate care
(treatments were considered effective if there was evidence that they led to significant improvement). A total
of 41 percent of those with a disorder actually sought treatment in the past year; this rate is significantly
higher than the 25 percent who obtained treatment a decade ago or the 19 percent who were treated two
decades ago.
About one-third of all visits for mental illness are to “alternative” practitioners such as herbalists or chiropractors, whose interventions show little evidence of effectiveness. About two of every five visits are to a
mental health specialist who is not a psychiatrist— psychologist, marriage counselor, social worker, etc.;
these people do best at offering well-established treat-ments. Those least likely to receive care are the
elderly, racial minorities, and rural residents. On the other end of the continuum are the disproportionately
affluent. Nearly a third of visits for mental health care are made by people who don’t have a disorder.
“Maybe they’re nipping things in the bud,” said Kessler, “we just don’t know.” Men don’t seek care as
quickly as White women.
How long do people wait to go for treatment if they have symptoms of mental disorder? The average
delay is almost a decade. The sooner in life an illness begins, the longer the delay and the more
persistent the disor-der. Delay also depends on the specific disorder. Average time of delay for bipolar
disorder is 6 years; for generalized anxiety disorder it is 9 years; for attention-deficit hyperactivity disorder,
13 years; and for specific phobia, 20 years.
Elias, M. (2005, June 7). Mental illness: Surprising, dis-turbing findings. USA Today, p. 8D.
Kessler, R. C., et al. (2005) Lifetime prevalence and age-of-onset distributions of DSM-IV Disorders in the
National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593–602.
II. The Psychological Therapies (pp. 606–618)
Feature Film: Ordinary People and Psychotherapy Winner of four Academy Awards, including the award
for best picture, Ordinary People contains some of the best portrayals of psychotherapy in motion picture
his-tory. Although the entire film is too long to show in most classes, you could assign it for out-of-class
view-ing or show selected segments in class. Perhaps the most moving and powerful segment comes
toward the end of the film as guilt-ridden Conrad Jarrett, with the help of his therapist, Dr. Berger,
achieves a new per-spective on himself and his family. More specifically, Conrad gains insight into his
involvement in the boat-ing accident that killed his oldest brother, Bucky. The segment vividly
demonstrates the empathic, trusting, caring relationship between therapist and client that is one of the
important commonalities among psychother-apies. The segment begins 98:07 minutes into the film and
runs 7:15 minutes. If you show this scene, be sure to explain that it comes after many therapeutic
sessions in which Conrad has wrestled with self-blame compli-cated by alienation from his parents,
particularly his mother. Other brief clips that effectively portray psy-chotherapy are sprinkled throughout
the film, including one of Conrad’s father’s first visit to Berger at 74:12 minutes (running 4:31 minutes).
Indicating that he has come to talk about his son and voicing reservations about the utility of therapy,
Calvin Jarrett eventually admits that he needs Berger’s help in understanding himself. Finally, to
demonstrate obstacles to seeking therapy, you might show the restaurant scene beginning at 81:40
minutes (running 2:34 minutes) in which Conrad’s mother, Beth, demonstrates obvious defen-siveness.
She tells her husband Calvin, “I don’t want to see any doctors or counselors. I’m me. This is my fami-ly.
And if we have problems, we will solve them in the privacy of our own home. Not by running to some kind
of specialist every time something goes wrong.”
A. Psychoanalysis (pp. 606–608)
Lecture/Discussion Topic: Good Candidates for Psychoanalysis
Psychoanalysis is long and costly. Thus, before psycho-analysis begins, the therapist often has a series
of ses-sions to determine how appropriate the treatment may be for the patient. Psychoanalysts seem to
agree that the following four personal qualities are crucial to deter-mining whether analysis will be
successful.
1
Motivation. The person needs strong internal moti-vation to persist in treatment that will require
sev-eral sessions per week for several years.
2
Capacity to form interpersonal relationships. The potential patient must have the capacity to form,
maintain, and ultimately detach from an intimate, trusting relationship.
3
Capacity for introspection and insight. The therapy requires natural curiosity about oneself and
the capacity for self-scrutiny.
4
Ego strength. The person must be able to accept the “rules” of psychoanalysis and be open to
painful facts and interpretations about himself or herself.
Sarason, I., & Sarason, B. (2005). Abnormal psychology (11th ed.). Upper Saddle River, NJ: Prentice Hall.
B. Humanistic Therapies (pp. 609–610)
PsychSim 5: Computer Therapist
This program is based on the famous ELIZA program. A person talks to the computer as he or she would
to a nondirective therapist. The computer picks up certain key phrases and responds accordingly. The
program also contains some historical information, along with a note on the limitations of computer
therapy.
Lecture/Discussion Topic: Computer-Assisted Psychotherapy
There have been many attempts to use the computer in therapy. ELIZA (see the previous description in
PsychSim) is only one. Roger Gould, a psychiatrist at UCLA, has designed the Therapeutic Learning
Program (TLP) to help patients clarify their problems and gradu-ally to resolve conflicts by developing
plans of action. At the beginning of each session, the patient “convers-es” with the computer. Later on, he
or she talks with a “real” therapist. “It’s a computer-assisted psychothera-py,” explains Gould. An
increasing number of psychi-atric hospitals are licensed to use TLP because it helps people talk to
themselves much as a therapist would talk to them.
The case of John, a businessman, provides a good example of how TLP works. In the first session, John
reports a high degree of stress and a change in appetite and energy level. The computer offers the client
several choices: “The stress I’m feeling in my work has to do with starting a new business . . . changing
jobs or careers . . . being criticized . . . .” From 15 choices, John picks “being criticized.”
The computer continues: “Are you feeling stress over your behavior in that you may be out-of-control in
any of the following ways? Drinking too often . . . gam-bling too much . . . spending too much money . . .?”
John answers that he drinks and spends too much.
At the end of the session, the computer provides an analysis of John’s situation, as well as some advice.
Speaking for John, the computer states, “It’s possible that these internal conflicts may be responsible for
some of the difficulty I’m having in dealing with the other sources of stress in my life. It may even be that
my loss of confidence in myself and my out-of-control behavior are causing or contributing to some of the
other stresses.” At this point the issue is pursued with a “live” therapist.
In the second session, with the continued help of the computer, John begins to define specific “action
steps.” After acknowledging a need to be more assertive with his boss, Simon, John gets support from
TLP. Again, speaking for John, the computer states: “The stress of being criticized in my work life makes
me feel angry. This is complicated by the fact that I am being pressured to stop drinking. I have trouble
dealing with this stress because I have difficulty stopping to think before reacting.” TLP recommends that
John draw up an action plan. It has two parts. First, he must admit a need to accept reasonable criticism
while pointing out to his boss the impossibility of his meeting short dead-lines without help. He will
negotiate for more staff. Second, he must relieve the burden of stress caused by his own unrealistic work
demands and become a person who can stand up for his rights.
In subsequent sessions John weighs the possible adverse effects of taking these action steps. With
the computer, he identifies 23 specific reservations. Once again, however, the computer is reassuring and
identi-fies specific thinking errors as well as fears that may be based on “old but not forgotten rules”
learned in child-hood. At the completion of the therapeutic process, John reports that he understands that
he has been “unin-tentionally colluding” with his boss by trying to per-form in a “heroic” manner. He
negotiates another full-time professional employee. His symptoms of stress disappear.
James Reagan, a psychologist who has used TLP with many of his patients, notes that computer
sessions sometimes help people whom therapists have been unable to reach. One woman who had been
in and out of psychiatric hospitals for 20 years was asked by the computer to indicate what childhood
events might be contributing to her problems. She checked off sexual abuse. It was the first time she’d
said that. Either she hadn’t been asked the question before or had avoided it. Somehow, the computer
enabled her to talk about it.
Indeed, many people seem more willing to make intimate disclosures to a machine than to a
counselor, at least in the early stages of therapy. In one study, patients at an alcohol treatment clinic
admitted to drinking 30 percent more often when asked by a computer than when asked by a human.
Women, in another study, were much more likely to disclose sexual problems to a com-puter than to a
female psychiatrist. “The computer doesn’t blush,” says Reagan. “It doesn’t get judgmental, it doesn’t
approve or disapprove. It’s just very patient.”
Critics object. Psychiatrist T. Byram Karasu, for example, argues that human therapists—even those
who think of therapy in terms of problem solving—do a lot more than transfer information. They spend
time with their patients, they pay attention, they care. “The basis of psychotherapy is a human interaction,
the genuine caring of a therapist for a patient,” says Karasu. “Until the computer is able to deliberate, then
it is not a psy-chotherapeutic process.”
Defenders counterargue. “Computers may be able to do better with some people,” says psychiatrist
Kenneth Colby, “because those people won’t see a ther-apist at all.” For people who find the thought of
psycho-logical help distasteful, it may be less disturbing to imagine sitting at a computer than lying on a
couch.
Marion Jacobs randomly divided 90 patients with mild to moderate psychological problems into two
groups. In one group, each patient saw a psychothera-pist for 50 minutes each week for 10 weeks. In the
other group, each patient used the TLP software program for 10 sessions supplemented by brief visits
with the thera-pist for 10 to 15 minutes weekly. Participants in both groups showed a significant decrease
in depression, anxiety, and perceived stress at the end of treatment. At a 6-month follow-up, patients in
both groups reported treatment to have been effective. Patients generally pre-ferred the more intensive
interaction with a therapist but they found the computer-aided treatment equally effective.
C. Barr Taylor and Kristine Luce have provided a highly favorable review of computer-and Internet-based
psychotherapy interventions. They conclude that com-puters can make psychological assessments more
effi-cient, more accurate, and less expensive. In addition, computer-assisted therapy seems to be as
effective as face-to-face therapy for treating anxiety disorders and depression. And, like assessment, it
can be delivered at lower cost. Finally, the reviewers argue that the Internet can provide effective
psychosocial support and group therapy. Studies indicate that Internet-based support groups are
beneficial, with communication patterns being similar to those found in face-to-face groups. The reviewers
call for more research to determine the spe-cific advantages and disadvantages of computer and Internetbased services. Nonetheless, they conclude that both are likely to play an increasingly important role in
mental health assessment and intervention.
As reported by Michael Price, psychologist Richard Munoz advocates the use of Internet-based interventions to underserved communities, particularly those in poor, rural areas. A single site can simultaneously
serve a nearly unlimited number of people. Because many rural villages now have Internet cafés,
interventions could reach those who would otherwise receive no help. With his colleagues, Munoz
recently demonstrated the effectiveness of an Internet-based smoking cessation program that reached
4000 participants in 74 countries. Munoz maintains interventions could work with other serious problems,
including depression, alcohol abuse, and pain management. A major challenge is to translate
interventions into multiple languages and cultures. To fund his initiative, Munoz is looking for grants from
the World Health Organization and from foundations and corporations interested in global health issues.
Christensen, A., & Jacobson, N. (1994). Who (or what) can do psychotherapy: The status and challenge of
non-professional therapies. PsychologicalScience,5,8–14.
Davis, L. (1990, September/October). The doctor is on. InHealth,60–63.
Hamilton, A. (1999, May 24). On the virtual coach. Time, 71.
Jacobs, M. K., et al. (2001). A comparison of computer-based versus traditional individual psychotherapy.
Professional Psychology: Research and Practice, 32, 92–96.
Joyce, C. (1988, February). Learning to talk to yourself. Psychology Today, 47.
Price, M. (2008, October). Underserved communities may benefit from Web interventions. Monitor on
Psychology, p. 12.
Taylor, C. B., & Luce, K. H. (2003). Computer-and Internet-based psychotherapy interventions. Current
Directions in Psychological Science, 12, 18–22.
Classroom Exercise: Understanding Empathy
Carl Rogers encouraged therapists to exhibit empathy. When they accurately sense and reflect their
clients’ feelings, he suggested, clients increase in self-under-standing and self-acceptance. The text
suggests that establishing an empathic, trusting, caring relationship is one of the key components of all
effective psycho -therapy.
But how does one listen empathically? Peter and Dodge Fernald provide an exercise in which
students imagine themselves in the role of counselor and consider what they might or might not say in
displaying empathy. Handout 13–3, “Listening Empathically,” includes a statement by a client and 10
therapist responses (or thoughts) that students evaluate for empathic quality.
Explain that empathy is the act of adopting the client’s perspective, of walking in the client’s shoes.
The counselor’s task, argued Rogers, is
To assume, in so far as he is able, the internal frame of reference of the client, to perceive the world as the client
sees it, to perceive the client himself as he is seen by himself, to lay aside all perceptions of the external frame of
reference while doing so, and to communicate some-thing of this empathic understanding to the client.
After distributing the handout, give the following instructions: “As you listen to me role-play a client,
pre-tend you are a counselor or a therapist. Your task is to adopt my perspective, that is, the client’s
perspective. Try to see the world through my eyes. Imagine which of the ten statements listed at the
bottom of the handout might run through your mind as you adopt my point of view. Check only those that
demonstrate empathy.”
Read the statement aloud with feeling so that the students have a sense of the client’s sadness and
struggle. Give student about 5 minutes to check those responses that indicate an empathic perspective.
Have students form small groups, then reach consensus on what statements constitute empathy.
Alter-natively, ask volunteers from the full class to share their judgments. No doubt students will disagree.
For example, some will argue that the first statement communicates empathy because it indicates the
counselor’s desire to be helpful. However, it is not truly empathic because the client, even though he
struggles to express himself, indicates no concern about getting started talking. Nor is the second
statement empathic. Although the client’s statement may suggest indecisiveness, he indicates no specific
concern about indecisiveness, nor does he refer to instances of indecisiveness. Continue the discussion
by reviewing the remaining statements. Only items 3, 6, 7, 8, and 10 indicate empathic listening.
Fernald, P. S., ! Fernald, L. D. (1999). Empathy: The cornerstone of counseling. In L. T. Benjamin, B. F. Nodine, R. M.
Ernst, ! C. B. Broeker (Eds.), Activities handbook for the teaching of psychology (Vol. 4, pp. 393z396). Washington, DC:
American Psychological Association.
Classroom Exercise: Role-Playing to Demonstrate Client-Centered Therapy
William Balch uses student volunteers to demonstrate Rogers’ client-centered therapy (also called
person-centered therapy), which seems particularly well-suited for role-playing. Students who are
interested, perhaps even majoring, in drama may be willing and eager participants.
A week or so before the demonstration, recruit the volunteers and distribute Handout 13–4, which
explains the situation and the roles to be enacted: Pat (male or female), who is faced with several
conflicts, and Pat’s father, mother, and best friend. Each person discusses his or her problem with him in
a series of improvised two-way dialogues. Each provides some directive advice, but Pat remains
confused and uncertain. Finally, a nondirective therapist uses person-centered techniques to help him
clarify his feelings. If you are a counseling psychologist, you should play the therapist; otherwise elicit the
help of a counseling psychologist on campus.
During the exercise you may wish to serve as a stage manager by introducing Pat, ushering in and out
her parents, friend, and therapist, and providing appropriate commentary. Afterward, discuss the exercise
with both the participants and the rest of the class.
While the person-centered approach may be the easiest to role-play, other therapies also may be
enacted, particularly if you have interested drama students. Balch reports that students usually play their
roles plausibly and creatively. In a few cases they have become emotionally involved, particularly those
playing Pat. It is probably wise to screen the participants carefully, then provide an opportunity for them to
discuss their feelings after the demonstration.
Balch notes one interesting phenomenon in con-ducting the exercise. When talking to the therapist,
Pat typically speaks more slowly and at a lower pitch than when conversing with relatives or friends. He
also engages in more eye contact with the therapist and, in general, seems more relaxed. Noting the
effect may serve as a launching point for class discussion.
Randy Larsen and David Buss suggest that empathic listening is a conversational strategy that can
be developed. They suggest students practice with friends.
You might assign your students the task of role-playing a client-centered approach in conversational
dialogue with someone they know fairly well. They might ask a friend to describe a small problem from his
or her life. Their task is two-fold. First, they should repeat what the person says, precisely as they understand it (e.g., “What I hear you saying is . . . .”). Their second task is to reflect back the friend’s feelings
(e.g., “It seems you are feeling . . . about the situation.”). The friend will correct or elaborate on the
problem or feeling. After a few minutes, they should switch roles, with the friend being the empathic
listener and your student describing a small problem. If they role-play correctly, the two friends should feel
greater mutual understand-ing and should be encouraged to explore their problem and feelings about it
more fully. Have your students provide an informal report in class or brief written summary on their
success in carrying out the project. Their report might include some reflection on the possible obstacles to
empathic listening in everyday life.
Balch, W. R. (1983). The use of role-playing in a class-room demonstration of client-centered therapy. Teaching
of Psychology, 10(3), 173–174.
Larsen, R. J., & Buss, D. M. (2008). Personality psychology: Domains of knowledge about human nature (3rd
ed.). (p. 382). New York: McGraw-Hill.
Classroom Exercise: The Self-Concealment Scale
An important factor in effective humanistic therapy is providing clients with a safe environment in which
they feel free to express themselves. This permits them to disclose negative emotions and distressing
experiences, which is vital to their self-understanding and acceptance. Handout 13–5 is Dale Larson and
Robert Chastain’s Self-Concealment Scale, which was designed to measure the extent to which people
typically conceal or disclose personal information that they perceive as distressing and negative. Students
can score their responses simply by totaling the numbers before all the items. Total scores range from 10
to 50, with higher scores reflecting a greater tendency toward self-concealment.
Larson and Chastain reported that people who tended to conceal negative information about themselves were more likely to suffer from depression anxiety. In addition, several studies by other
researchers suggest that honest self-disclosure improves self-understanding and helps people to come
to terms with traumatic experiences. Although simply writing about the experience is often helpful, talking
with a therapist seems to bring additional benefits. For example, in one study, researchers found that in
comparison to those who simply wrote about traumatic events, those who talked about them in sessions
with a therapist were less anxious or depressed. In addition, those who only wrote had a short-term
increase in negative emotion, whereas those who expressed their feelings orally to a therapist did not
show this effect.
Research also indicates that self-disclosure may be beneficial for our physical health. For example, in one
study, researchers contacted people who had lost a spouse through accidental death or suicide. They
found that the more people had talked about the tragedy, the fewer health problems they had. Similarly,
first-year students given the opportunity to write about the problems and emotions they experienced in
leaving home and adjusting to college or university experienced fewer health problems and made fewer
visits to the campus health center than those not given this opportunity.
Burger, J. (2008). Personality (7th ed.). Belmont, CA: Wadsworth.
Larson, D. G., & Chastain, R. L. (1990). Self-concealment: Conceptualization, measurement, and health
implications. Journal of Social and Clinical Psychology, 9, 439–455.
Student Project: Dibs and Play Therapy Virginia Axline, a student of Carl Rogers, has extended the
client-centered approach to the treatment of children in play therapy. She has written Dibs: In Search
of Self, a book that is extremely popular with students. Easily read in an evening, it can be assigned in
preparation for class discussion of the humanistic therapies, and particularly of Rogers’ nondirective
approach. Alternatively, you can have students write a paper identifying the important elements of
client-centered therapy (e.g., active listening, genuineness, acceptance, empathy) used with Dibs.
The more general humanistic themes of becoming aware of one’s feelings as they occur, of
emphasizing conscious rather than unconscious material, of encouraging responsibility for one’s
actions, and of promoting growth and fulfillment are also clearly evident in the book. Axline, V. (1964).
Dibs: In search of self. Boston, MA: Houghton Mifflin.
Classroom Exercise: The Imposter Phenomenon
This exercise is appropriate for discussions of either humanistic or cognitive therapies. Fritz Perls has
used the term “catastrophic fantasy” to refer to our tendency to deprive ourselves of present joy due to a
largely un-conscious fear of being unmasked, that is, of being revealed as a fake and thus unworthy of
the respect of those we love and admire. Clinical psychologist Joan Harvey has popularized findings on
the imposter phenomenon (IP), a psychological syndrome based on intense, secret feelings of
fraudulence in the face of success and achievement. In her book If I’m So Successful, Why Do I Feel Like
a Fake?, she reports that a surprisingly large number of people in general, and approximately 70 percent
of high achievers, suffer from the phenomenon. Many students are likely to experience “imposter”
feelings.
Handout 13–6 contains the Harvey Imposter Phenomenon Scale. In scoring their responses, students
should reverse the numbers they circled for items 2, 4, 5, 7, 10, 11, and 14 (0 = 6, 5 = 1, 4 = 2, 3= 3, 2 =
4, 1 = 5, = 0 = 6). Then, they should add the numbers for all 14 items to obtain a final score. Total scores
can range from 0 to 84. The higher the score, the more troubled one is likely to be by “imposter” feelings.
Harvey provides many case studies of those suffering from IP. She opens her book with Leslie, a
graphic designer. Leslie reports a feeling of fear, of always having the sense that she is not going to get
the job done and that she’s not necessarily qualified to do it. In short, she feels she will not be able to give
her employers what they want. Leslie states, “It creates a sense of panic in me that they’re going to find
out I’m doing a terrible job and should be fired—and then I’ll never work again.”
Harvey identifies three basic symptoms of IP:
(1) the sense of having fooled other people into over-estimating one’s ability, (2) the tendency to
attribute success to some factor other than one’s intelligence or ability, and (3) the fear of being
exposed as a fraud.
In recommending how to deal with IP sufferers, Harvey incorporates the goals and approaches of
most of the psychotherapies discussed in the unit. For exam-ple, her suggestion to revise our ego ideal
reflects the humanistic theme that we need to grow in self-under-standing and self-acceptance. Her
advice to challenge our irrational beliefs—for example, that any mistake is a fatal flaw that must be
camouflaged—suggests a cog-nitive approach. Change our thoughts, writes Harvey, and we change our
feelings. Finally, she recommends tackling the IP by changing behavior. Her advice to relax, to change
specific work patterns, and to reinforce ourselves when the goal is reached demonstrates princi-ples of
classical and operant conditioning.
Harvey, J. (1985). If I’m so successful, why do I feel like a fake? New York: St. Martin’s Press.
C. Behavior Therapies (pp. 610–614) Feature Film: Harry Potter and the Prisoner of Azkaban
Some clinicians have applauded this film’s central theme of overcoming fear by confronting it. In one
memorable scene (DVD scene 10, at 32:00 minutes), the giant, good-natured Hagrid introduces
Harry and his classmates to Buckbeak, a hippogriff. The large, menacing bird elicits immediate fear
in everyone. All but Harry instinctively retreat. Harry hesitantly, inch-by-inch, approaches Buckbeak
until he makes contact. Harry’s fear subsides only to be rekindled when Hagrid unexpectedly picks
up Harry and places him on Buckbeak’s back. The bird takes off. Gliding above the trees, Harry’s
apprehension is transformed into exhila-ration. At 37:45 minutes, they land safely and by then
Buckbeak has become Harry’s friend. The scene mar-velously illustrates how exposure to what we
fear can be therapeutic.
In scene 11 (40:05 to 44:00 minutes), titled “Boggart in the Wardrobe,” the new Defense Against the
Dark Arts teacher, Professor Lupin, teaches the stu-dents to visualize their worst fears and transform
them into ridiculous, amusing portrayals. A giant spider is imagined wearing roller skates, the scary
Professor Snape is morphed into a hunched-over grandmother in silly clothes, and a hissing snake is
transformed into a gentle clown. Visualizing our fears as humorous and thus harmless can be helpful in
the process of desensitization.
Johnson, R. F. (2004, June 21). ‘Azkaban’ could have healing powers for kids’s fears. USA Today, p. 7D.
Classroom Exercise: Using Systematic Desensitization to Treat Eraser Phobia
Timothy Lawson and Michael Reardon describe a delightful classroom demonstration of systematic
desensitization in treating a phobia of chalkboard
erasers. You need a student volunteer from the back of the room who plays along with the exercise, and,
ideal-ly, a photograph of a chalkboard eraser and a small cage in which you can lock a real eraser.
Begin by reviewing the three major elements of systematic desensitization, including (1) the creation of an
anxiety hierarchy that orders fear-producing stimuli from the lowest to highest, (2) the learning of the
relax-ation response, and (3) the progressive association of each hierarchy item with relaxation. Explain
that the therapist may accomplish this association by having the client imagine hierarchy items or by
actually presenting the feared items. Often both strategies are used.
Explain that your “client” has always sat at the back of the room because of a phobia of chalkboard
erasers. Further, tell your class that you have already worked with him to develop an anxiety hierarchy,
have taught progressive relaxation, and have desensitized him to a photograph of a chalkboard eraser.
Show the class the photograph and move it toward the student to demonstrate that he has been
desensitized. Explain that you now plan to desensitize him to items higher in the anxiety hierarchy. From
under your desk produce a small metal cage with an eraser padlocked in it. Move it slightly in the
direction of the student who should dis-play obvious anxiety. Ask him to take some deep breaths and
invoke the relaxation response. Once he is relaxed in the presence of the padlocked eraser, remove it
from the cage, and repeat the process. Move the eras-er closer and closer until, finally, the student can
touch the eraser while remaining relaxed. At each step ask him if he is feeling anxious and move closer
only after he reports his anxiety has subsided. End the demonstra-tion by noting that the student did not
have real eraser phobia but that the technique is used in treating real phobias.
You can give a longer demonstration by construct-ing an actual hierarchy along with a detailed
description of how it was developed. Have the student volunteer report subjective units of discomfort at
each step. You can also engage the class in a discussion of the relative merits of imagined,
photographed, or actual fear stimuli. Finally, you may want to select the student volunteer a day or two
before the actual exercise and coach him or her on how to respond to each step in the process.
Lawson, T. J., & Reardon, M. (1997). A humorous demonstration of in vivo systematic desensitization: The
case of eraser phobia. Teaching of Psychology, 24, 270–271.
Student Project: Practicing Systematic Desensitization
Students may practice systematic desensitization on themselves. First, they must identify a specific fear
they would like to overcome—for example, the fear of taking tests. Next, they must construct an anxiety
hierarchy. Handout 13–7, which is Jim Eison’s hierarchy for test anxiety, can be readily adapted by
students to fit their own situation.
Then, students must train themselves in progressive relaxation, as suggested by Anthony Grasha in
Handout 13–8. It might be best for them to practice the procedure for a few days before combining
relaxation with the steps of the anxiety hierarchy.
Finally, they should try the actual desensitization procedure for 10 days. After relaxing, they are to
imag-ine the first item in the hierarchy. If they feel no anxi-ety, they should proceed to the second step. If
at any time they experience anxiety, they should switch off the mental image and go back to deep
relaxation. A scene should be imagined over and over until they can feel completely relaxed while
imagining it. Eventually, of course, they should practice the imagined behaviors in actual situations. You
might have volunteers report back to class on their success.
Eison, J. (1987). Using systematic desensitization and rational emotive therapy to treat test anxiety. In V. P.
Makosky, C. C. Sileo, L. G. Whittemore, C. P. Landry, &
M. L. Skutley (Eds.), Activities handbook for the teach-ing of psychology (Vol. 2, p. 162). Washington, DC:
American Psychological Association.
Grasha, A. (1987). Practical applications of psychology (3rd ed.). New York: HarperCollins.
Lecture/Discussion Topic: Virtual Iraq
Virtual reality exposure (VRE) therapy has been used to treat post-traumatic stress syndrome (PTSD).
Virtual Iraq, developed by clinical psychologist Albert Rizzo, as reported by Sue Halpern, provides an
excellent example. Victims of PTSD are often reluctant to under-go therapy because friends may see
them as weak. In contrast, virtual reality therapy is often perceived as comparable to playing a video
game. Telling buddies that you are going off to do VR is a lot easier than telling them you are going to see
a shrink.
Rizzo adapted the video game “Full Spectrum Warrior” to create his clinical tool. Virtual Iraq enables
patients to work through their combat trauma in a computer-simulated environment. Similar to other virtual reality approaches, the intervention utilizes a head-mounted display (a helmet with a pair of video goggles), earphones, and a scent-producing machine. It requires the patient to revisit the trauma over and
over again, and through eventual habituation rid it of its overwhelming power. The basic notion is to
disconnect the memory from the painful reactions to the memory so that everyday events, such as a car
backfiring or trash blowing across an expressway, no longer trigger fear or panic. Typically, there are 12
sessions in all, each lasting about 2 hours, over a 6-week period.
In constructing Virtual Iraq, Rizzo began with two basic scenarios, an Iraqi street scene and a Humvee
moving along an Iraqi highway. Therapists have a vari-ety of ways—visual, aural, tactile, even olfactory—
to customize these basic scenes. At the click of a mouse, the therapist can put the patient in the driver’s
seat of the Humvee, in the passenger’s seat, or in the turret behind the machine gun. The vehicle moves
at a speed determined by the patient. A sandstorm can be raging (the driver can turn on the windshield
wipers), a dog can be barking, the inside of the vehicle can smell rank. Giving the therapist so many
options increases the like-lihood of evoking the patient’s actual experience. Engaging the patient on so
many sensory levels allows for total immersion in the past experience.
Trained therapists are crucial to the success of the intervention. New stimuli must be introduced
gradually so that the experience is not overwhelming and thereby self-defeating. The therapist must
understand the patient and know which stimuli to select and when to introduce them. Initially, a patient
may only be able to sit in the Humvee. Rizzo claims that virtual reality exposure therapy for PTSD “is
really intuitive. We provide a lot of options and put them into the hands of the clinician.”
Currently, the Department of Defense is testing Virtual Iraq—one of three virtual-reality programs
it has funded for PTSD—at six locations throughout the United States. Preliminary results from a relatively
small sample suggest the intervention is effective.
Halpern, S. (2008, May 13). Virtual Iraq. The New Yorker, 33–37.
Lecture/Discussion Topic: Exposure Therapy— Improving Its Effectiveness
Christopher Cain and his colleagues have studied fear extinction in mice, which may have important
implications for the use of exposure therapy. In these techniques, with repeated exposure, people
become less responsive to people, objects, or situations that once petrified them.
The UCLA researchers taught mice to fear harm-less white noise by associating it with a mild shock
delivered to the floor of the experimental cage. After only a couple of trials the mice “froze” for about 72
seconds, or 60 percent of the two minutes of white noise. The noise had come to function as a
conditioned stimulus for fear.
The researchers then separated the mice into three groups and assessed how easily they overcame
their aversion to white noise when they heard it 20 times for two minutes each time without shocks. The
groups differed only in the intervals between each 6, 60, or 600 seconds.
Unlearning a fear typically takes much longer than acquiring it. Indeed, the mice feared the white
noise after only two pairings with shock but needed far more than two exposures to overcome it.
Nonetheless, Cain and his colleagues report that fear extinction occurred much more quickly when the
time between stimulus presentations was relatively short. Indeed, the 6-second-gap mice stopped
showing significant freezing after about 10 presentations of white noise, while the mice in the other two
groups never really stopped freezing.
“This very strong finding,” states co-author Mark Barad, “is already inspiring a search for a similar pattern of response in human anxiety patients. It’s part of a wave of important discoveries about fear
extinction, findings that will transform both the practice of behav-ior therapy and the use of drugs as
adjuncts to psychotherapy in the next few years.”
Cain, C. K., Blouin, A. M., & Barad, M. (2003). Temporally massed CS presentations generate more fear
extinction than spaced presentations. Journal of Experimental Psychology: Animal Behavior Processes, 29,
323–333.
Lecture/Discussion Topic: Therapy and Totalitarian Control
The behavior therapies—in particular, aversive conditioning—will have some older students conjuring up
images of George Orwell’s 1984 and Stanley Kubrick’s film of A Clockwork Orange (available on DVD). In
the latter, Alex, a young hoodlum, is appre-hended by police after a series of sexual and violent crimes.
While in prison he volunteers for the “Ludoveck Treatment,” which presumably cures crimi-nals in a few
weeks. Alex is injected with a drug that makes him violently ill; while under its influence, he is forced to
view films that graphically portray sexual and aggressive actions. After repeated pairings of the conditioned stimulus (sexual and violent images) with the unconditioned stimulus (nausea-producing drug),
sexual and violent thoughts come to make Alex extremely ill.
Two points are worth making in regard to this fic-tional example. First, psychologists do not use aversive
conditioning in this way. Typically, the client knows all about the procedure and consents to it. Moreover,
its aim—for example, in the treatment of smoking or drinking—is toward increased self-control rather
than control by others. Second, A Clockword Orange simpli-fies the situation. It overlooks the influences
of cogni-tion. After treatment, Alex would know that sexual and violent actions would not induce illness.
In short, peo-ple’s feelings and behavior cannot be so easily con-trolled as A Clockwork Orange implies.
Classroom Exercise: Modeling
You can extend the text discussion of the behavior therapies by explaining how therapists have used
observational learning to help people overcome fears of snakes, spiders, and dogs. Nigel Barber
describes a classroom demonstration in which modeling is used to reduce many students’ fear of a
laboratory rat. Assuming that you have access to a laboratory rat and a transport cage, the demonstration
can be an effective way to introduce the behavior therapies. It takes approximately 30 minutes.
Begin by having students complete and score Handout 13–9, the Fear of Rats Scale (FRS). The total
score is simply the sum of the ratings for all items, with higher scores reflecting greater fear. After
students have completed the scale, have them turn the page over. Reveal the rat in its transport cage and
give the following instructions.
We now want to test your insight about rats. I want you to assess the age of the rat in days and write it on the
back of your FRS. In order that everyone has a good chance to look at the rat, I want you to pass it around the
room.
When the cage has been passed to everyone and returned to you, make this additional request:
Now I need the assistance of five volunteers to assess the friendliness of the rat. In order to do this, it is
necessary to put your hand into the transport cage and pet the animal. Gloves are available for this purpose, if
you wish to use them. If you wish to volunteer, please raise your hand.
Barber suggests choosing both men and women volunteers to come forward and in full view of the
class pet the rat until deciding on the animal’s level of friendliness. Have them then return to their desks
and write the word volunteer on the back of their FRS. Also have them rate the rat’s friendliness on a 7point scale ranging from not friendly at all (1) to extremely friendly (7). Finally, have all students take and
score the FRS again.
Inform students that the purpose of the demonstration has been to show how modeling can be used
in therapy. In participant modeling, the client is exposed to a feared object in the presence of the therapist
and is encouraged to have contact with it. For example, a snake phobic approaches the snake and
eventually handles it. This procedure is more effective than symbolic modeling in which the client merely
observes an expert handling the snake. However, both strategies can reduce fear. Have students
calculate whether their pretest and posttest FRS scores showed a decline in fear. A show of hands will
confirm the effect. Collecting and analyzing the scores between class sessions will enable you to
calculate and report whether participant modeling was more effective than symbolic modeling.
Barber, N. (1994). Reducing fear of the laboratory rat: A participant modeling approach. Teaching of
Psychology, 21, 228–230.
Student Project: Modifying an Existing Behavior
In Unit 6, we suggested a project in which students would modify some existing behavior. If you did not
assign it then, you might do so now. It will not only demonstrate the application of operant conditioning
but it will also show that the aim of behavior modification is often toward increased self-control rather than
control by others.
Classroom Exercise: Assessing Assertiveness
An important behavior therapy is assertiveness training. Jim Eison designed Handout 13–10 to help
students distinguish among assertive, nonassertive, and aggressive responses to common situations. He
emphasizes that the test is designed simply to arouse student interest and to stimulate class discussion;
reliability, validity, and normative data have not been collected. You might also ask students to devise
their own assertive, nonassertive, and aggressive replies to the designated situations.
Using the key below, students should tally the num-ber of nonassertive, aggressive, and assertive
responses they gave to get some idea of their dominant style.
Assertiveness training takes different forms. In Other forms of assertiveness training, the Broken
some cases, the therapist models socially assertive Record and Fogging techniques, are sometimes used
for behavior, then encourages the individual to practice the people who have difficulty denying requests.
In the for-same behavior while the therapist provides feedback. the person is taught to deny a request,
briefly This role-playing may also be practiced within a group explaining why, and then repeat the denial
without variation each time the request is made. The film What Could I Say? (Research Press,. In the
latter, the 18 minutes) presents 20 vignettes that illustrate com-person is taught to repeat in great detail
every possible situations requiring assertive responses. After each reason for denying the request. scene,
time is provided for viewers to discuss appropriate. People often worry that assertiveness will be per-ate
responses. perceived as aggressiveness. A definition provided by Robert Alberti and Michael Emmons is
useful in high-lighting the difference: “Assertion is behavior that enables a person to act in his own best
interest and to stand up for himself without undue anxiety and to exercise his rights without denying the
rights of others.” M. J. Smith has provided instructions to help people to be appropriately assertive and
reduce the guilt they may feel about having been assertive. Note that these instructions reflect a bias (that
self-interest comes first) and illustrate how values penetrate the recommendations of psychologists. You
might ask students if they believe it’s always wise to follow them. The specific instructions appear in the
right-hand column.
I have the right to
—say no
—not do what someone, even someone close, asks me to do
—enjoy myself
—feel good about myself
—not be responsible for other people’s problems
—not do everything I can to help everyone
—feel angry
—be “illogical”
—not care
—not know the solution to a problem
—change my mind
—make mistakes
—not pay forever for my mistakes
Source: WHEN I SAY NO, I FEEL GUILTY by Manuel
J. Smith, copyright © 1975 by Manuel J. Smith. Used by permission of Doubleday, a division of Random
House, Inc.
Eison, J. (1987). Assessing student assertiveness. In V. P. Makosky, C. C. Sileo, L. G. Whittemore, C. P.
Landry, & M. L. Skutley (Eds.), Activities handbook for the teaching of psychology (Vol. 2, pp. 294–298).
Washington, DC: American Psychological Association.
Smith, M. J. (1975). When I say no, I feel guilty. New York: Doubelday.
Yates, B. (1985). Self-management. Belmont, CA: Wadsworth Publishing Co.
D. Cognitive Therapies (pp. 614–617)
Lecture/Discussion Topic: Strategies to Correct One’s
Thinking In The Feeling Good Handbook, David Burns, MD, a psychiatrist, suggests 10 ways to untwist
the common cognitive distortions that typically underlie anxiety and depression. First, ask your students if
they recognize any of the following cognitive distortions as their own.
1. All-or-nothing thinking: You look at things in absolute, black-and-white categories.
2. Overgeneralization: You view a negative event as a never-ending pattern of defeat.
3. Mental filter: You dwell on the negatives and ignore the positives.
4. Discounting the positives: You insist that your accomplishments or positive qualities “don’t count.”
5. Jumping to conclusions: (a) Mind reading—you assume that people are reacting negatively to you
when there’s no definite evidence for this; (b) Fortune-telling—you arbitrarily predict that things
will turn out badly.
6. Magnification or minimization: You blow things way out of proportion or you shrink their
importance inappropriately.
7. Emotional reasoning: You reason from how you feel: “I feel like an idiot, so I really must be one.”
Or “I don’t feel like doing this, so I’ll put it off.”
8. “Should statement”: You criticize yourself or other people with “shoulds” or “shouldn’ts.” “Musts,”
“oughts,” and “have tos” are similar offenders.
9. Labeling: You identify with your shortcoming. Instead of saying “I made a mistake,” you tell yourself, “I’m a jerk,” or “a fool,” or “a loser.”
10. Personalization and blame: You blame yourself for something you weren’t entirely responsible
for, or you blame other people and overlook ways that your own attitudes and behavior might
contribute to a problem.
Next, present Burns’ 10 suggestions for correcting the distortions.
1. Identify the distortion: Write down your negative thoughts so you can see which of the 10
cognitive distortions you’re involved in. This will make it easier to think about the problem in a
more positive and realistic way.
2. Examine the evidence: Instead of assuming that your negative thought is true, examine the actual
evidence for it. For example, if you feel that you never do anything right, you could list several
things you have done successfully.
3. The double-standard method: Instead of putting yourself down in a harsh, condemning way, talk
to yourself in the same compassionate way you would talk to a friend with a similar problem.
4. The experimental technique: Do an experiment to test the validity of your negative thought. For
example, if, during an episode of panic, you become terrified that you’re about to die of a heart
attack, you could jog or run up and down several flights of stairs. This will prove that your heart is
healthy and strong.
5. Thinking in shades of gray: Although this method might sound drab, the effects can be
illuminating. Instead of thinking about your problems in all-or-nothing extremes, evaluate things
on a range from 1 to 100. When things don’t work out as well as you had hoped, think about the
experience as a partial success rather than a complete failure. See what you can learn from the
situation.
6. The survey method: Ask people questions to find out if your thoughts and attitudes are realistic.
For example, if you believe that public-speaking anxiety is abnormal and shameful, ask several
friends if they ever felt nervous before they gave a talk.
7. Define terms: When you label yourself “inferior” or “a fool” or “a loser,” ask, “What is the definition
of ‘a fool’?” You will feel better when you see there is no such thing as “a fool” or “a loser.”
8. The semantic method: Simply substitute language that is less colorful and emotionally loaded.
This method is helpful for “should statements.” Instead of telling yourself “I shouldn’t have made
that mistake,” you can say, “It would be better if I hadn’t made that mistake.”
9. Re-attribution: Instead of automatically assuming that you are “bad” and blaming yourself entirely
for a problem, think about the many factors that may have contributed to it. Focus on solving the
problem instead of using up all your energy blaming yourself and feeling guilty.
10. Cost-benefit analysis: List the advantages and disadvantages of a feeling (like getting angry when
your plane is late), a negative thought (like “No matter how hard I try, I always screw up”), or a
behavior pattern (like overeating and lying around in bed when you’re depressed). You can also
use the cost-benefit analysis to modify a self-defeating belief such as, “I must always try to be
perfect.”
Burns, D. (1999). The feeling good handbook (Revised Ed.). New York: Plume.
Classroom Exercise: Frequency of Self-Reinforcement Questionnaire
To complement and extend the text treatment of cognitive therapy, you may want to introduce students to
the concept of self-reinforcement and its importance in pre-venting and overcoming depression. Handout
13–11 is Elaine Heiby’s Frequency of Self-Reinforcement Scale (FSRS). Students should score one point
for a “True” response to items 1, 2, 4, 7, 10, 12, 14, 17, 18, 19, 20, 24, 25, 26, and 29 and one point for a
“False” response to 3, 5, 6, 8, 9, 11, 13, 15, 16, 21, 22, 23, 27, 28, and
30. Total scores can range from 0 to 30, with higher scores reflecting a greater tendency to engage in
self-reinforcement. The mean score for undergraduates is about 17.
According to Heiby there are at least two important reasons that people may engage in a low level of
self-reinforcement and be depressed. First, they may set unrealistically high goals for themselves; that is,
they have aspirations beyond any hope of attainment.
Second, they may fail to attend to or discriminate a tar-get response when it occurs; that is, they fail to
acknowledge success. Research has indicated that self-reinforcement training can be an effective
treatment for depression.
Heiby, E. (1983). Assessment of frequency of self-reinforcement. Journal of Personality and Social
Psychology, 44, 1304–1307.
Lecture/Discussion Topic: Overcoming the Fear of Public Speaking
Survey research indicates that the greatest fear of most Americans is speaking before a group. Michael
Motley’s practical advice not only may help your stu-dents in dealing with their own phobia of public
speak-ing, but it can also be used to introduce the cognitive therapies. Motley’s recommendations
assume that feel-ings and responses to events are strongly influenced by thinking.
The most familiar aspects of speech anxiety are its physical symptoms—sweaty palms, dry mouth,
increased heart rate, butterflies in the stomach. A more important aspect of speech anxiety, notes Motley,
is how we interpret the anxiety. Some people view the physical symptoms as a positive sign that they are
emo-tionally ready for the speech. Most of us, however, interpret the feelings as fear. To justify our fear
we begin to imagine horrible consequences if our speech is less than perfect: “The audience will ridicule
me if I make a mistake. I’ll be embarrassed to death.” Motley argues that such beliefs are irrational,
because audi-ences usually ignore errors and awkwardness as long as they get something out of the
speech. Research has also found that most people report noticing little or no anxi-ety in a speaker.
Indeed, there is little relationship between the evaluations of individuals trained to detect anxiety cues and
the degree of anxiety actually felt by the speakers.
Excessive anxiety, reports Motley, is especially common when a speech is viewed as a performance.
Expecting to be evaluated or being uncertain about the proper way to behave arouses anxiety in almost
any situation. A more useful and accurate orientation is to view speeches as communication, the sharing
of ideas with others who are more interested in the content of the message than in analyzing or criticizing
its presentation. Speech making should thus be viewed as a form of everyday conversation.
Motley has a simple exercise to help students view public speaking in this new way. As the student
speaker approaches the podium, Motley dismisses the audience temporarily and begins a conversation
with the speaker. He instructs him or her to forget about giving a speech and simply talk spontaneously,
using prepared notes as a guide. Most students follow his lead, speaking conversationally and without
oratorical flair. They are then told to maintain the conversational style while the audience gradually
returns, a few at a time.
Motley gives these specific tips for speakers.
1. Decide on your specific objectives first. Know one or two major points you want to communicate.
2. Put yourself in your audience’s place. Speak to them on their terms, in their language.
3. Don’t memorize, don’t read. Except for a few memorable phrases or examples, be as
spontaneous as possible. Use brief notes.
4. Speak to one person at a time. Looking at and talking with individuals in the audience helps keep
you natural.
5. Try not to think about your hands and facial expressions. Concentrate instead on what you want
to get across. Conscious attention to gestures leads to awkwardness.
6. Take it slow and easy.
7. Speak the way you talk. Speak as you do in casual conversation with someone you respect.
8. Ask for advice and criticism. Solicit frank criticism from someone you trust, focusing on what
might have prevented you from accomplishing your objectives.
Motley summarizes: “For most of us, giving a speech is an important and novel event. It’s natural and
appropriate to feel some anxiety. A speaker’s aim should be to keep this natural nervousness from
cycling out of control: not to get rid of the butterflies but to make them fly in formation.”
At Georgia State University, psychologist Page Anderson is using virtual reality exposure therapy
(VRE) to help people overcome public speaking phobia. Anderson intends to compare the efficacy of
VRE with cognitive behavioral therapy. For those learning to over-come their fear of public speaking,
Anderson’s virtual audience will be able to raise their hands and ask questions. VRE has been used
primarily to help clients over-come fears of flying, heights, and, in some cases, animals. It is less
commonly used in addressing interpersonal fears.
Motley, M. (1988, January). Taking the terror out of talk.
Psychology Today, 46–49. Tricoles, R. (2004, November 10). Head games: High-tech gear helps conquer fears.
Message posted at www.gsu.edu/gastate_2200.html.
Student Project: Mood-Memory Repair
You can extend the text discussion of cognitive therapy for depression with a more detailed discussion of
mood memory repair. In his helpful book Memories That Matter: How to Use Self-Defining Memories to
Understand and Change Your Life, psychologist Jefferson Singer describes the research that underlies
using mood memory repair in treating depression and then provides readers with specific strategies for
applying it to their own lives.
Mood memory repair recognizes that our memories are mood-congruent. As Myers notes in Unit 7A,
Memory, our moods bias our recall of the past. We seem to associate good or bad events with their
accompanying emotions, which in turn become retrieval cues. Being depressed sours our memories by
priming negative associations, which we then use to explain our cur-rent mood. Similarly, being in a
positive mood leads us to recall the world through rose-colored glasses.
Our mood’s effect on retrieval helps explain why moods persist. Research on mood and memory, Singer
argues, indicates that we can become mood repairers by
(1) keeping our mental and physical energy at good, healthy levels; (2) arranging our immediate physical
environment in ways that make it easier to access positive, specific memories; (3) taking steps to
increase our store of positive memories filled with specific images and concrete evidence of the good
things in our lives;
(4) distracting ourselves from worries and negative thoughts; and (5) after we have broken the worry
cycle, focusing on the positive aspects of our current experiences.
To break depression’s vicious cycle or merely to raise our experience of well-being, Singer makes the
following specific recommendations in his “mood-memory repair kit”:
1
Mood-memory makeover list: Survey the room in your residence hall, apartment, or home where
you spend the most time for any objects that evoke negative memories—for example, photos, jewelry,
cosmetic items, sports equipment. Replace them with comparable items that evoke positive memories.
2
Go-to memories: Recall five of your happiest memories. Visualize and savor these experiences
until they become “go-to memories” that can be counted on to lift your spirits when they begin to sag.
3
Lemons-into-lemonade memories: Identify two strong negative memories. Try to identify positive
aspects of both memories. For example, if it is memory of a past failure, think of how it may have
redirected your life in some constructive way. If it is recall of a broken relationship, think of how it led to
the formation of new friendships.
4
Positive distracting activities: Unhappy, depressed people often find that breaking the focus on
them-selves is the healthiest antidote to the ruminating blues. Identify positive activities that fit your
schedule and are both economical and convenient—making bread with friends, attending a movie or
concert, or simply some enjoyable physical exercise—that can become ready distractions when you
begin to worry. Don’t make this too complex. Start with one activity and when you build it into your
routine, add a second or third. These four steps are crucial. Additional steps, what Singer calls “mood
accessories,” include developing some surefire pick-me-up lines or key phrases that prime positive
thoughts, such as “Remember the . . .” (a past positive experience), using the don’t-go-there rubber band
(they do come in different colors!), and, finally, making “nose candy” readily available, that is, favorite
smells that trigger favorite memories from your childhood (e.g., popcorn, hot dogs, perfumes, body
washes, scented candles).
Challenge students to follow Singer’s recommendations and report their impact either in writing or in
an oral report to the class. If your students do this for even a few days or a week, they will surely come to
a better understanding and appreciation of the cognitive-behavioral approach.
Singer, J. (2005). Memories that matter: How to use self-defining memories to understand and change your life.
Oakland, CA: New Harbinger.
E. Group and Family Therapies (pp. 617–618)
III. Evaluating Psychotherapies (pp. 619–628)
A. Is Psychotherapy Effective? (pp. 619–622)
PsychSim 5: Mystery Therapist
Students should work this activity after they have read about the basic psychotherapies, and you have
lectured on them. The activity reviews the major perspectives on psychological disorders and therapy and
presents an interactive exercise in which students read brief fragments of case studies and are asked to
identify the type of therapy exemplified in each case.
Lecture/Discussion Topic: The Consumer Reports Study The November 1995 issue of Consumer
Reports (CR) reported survey results on the effectiveness of psychotherapy. CR’s 180,000 readers
had been asked to fill out the mental health section of a much longer survey “if at any time over the
past three years you experienced stress or other emotional problems for which you sought help from
any of the following: friends, relatives, or a member of the clergy; a mental health professional like a
psychologist or a psychiatrist; your family doctor; or a support group.” Twenty-two thousand readers
responded to the entire survey; of these, approximately 7000 completed the mental health section. Of
these 7000, about 3000 had just talked to friends, relatives, or clergy and about 4000 had turned to
some combination of mental health
professionals, family doctors, and support groups. Of the 4000, a total of 2900 saw a mental health
professional. As a whole, the respondents were well-educated and predominantly middle-class. About
half were women and the median age of the sample was 46.
Among the most important results were the following:
•
Psychotherapy helped 9 out of 10 patients feel significantly better. Almost half (44 percent) who
reported their emotional health as having been very poor now reported feeling good.
•
Those in psychotherapy more than six months did the best. Long-term treatment was
considerably more effective than short-term treatment.
•
Psychotherapy alone did not differ in effectiveness from medication plus psychotherapy.
•
No specific form of psychotherapy did better than any other for any disorder.
•
Psychologists, psychiatrists, and social workers did not differ in their effectiveness as treaters, but
they all did better than marriage counselors and long-term family doctors.
Martin Seligman contrasts the Consumer Reports large-scale survey study with the more traditional
efficacy studies in psychology in which patients are randomly assigned into specific treatment groups of
fixed duration. He argues that the studies complement each other and that both contribute to our
understanding of the effectiveness of psychotherapy.
In a more recent survey of 3079 readers, CR com-pared drug therapy with psychotherapy. Focusing on
the disorders of depression and anxiety, the organization reported that a combination of “talk” therapy and
drugs often proved most effective. CR concluded that each therapy worked at a different pace, with those
taking drugs showing substantial improvement within a few visits. Those who chose mostly talk therapy
improved more gradually. However, talk therapy was almost as effective as the combination if it lasted for
13 or more visits. (In the 1995 survey, respondents averaged well over 20 visits with a mental health
professional; in the current survey, the average was 10 visits—a troubling trend, notes CR.) Although
drugs worked more quickly, it often took trial and error to find one that did not have unacceptable side
effects. For example, 40 percent of those who took antidepressants complained of adverse sexual side
effects.
CR also reported that primary-care doctors were effective in treating people with mild problems, but
mental health specialists produced significantly better results for those with more serious disorders.
Those respondents who expressed greatest satisfaction with their care and who had the best outcomes
were more likely to:
•
Research their problem before seeking help.
•
Interview with more than one professional.
•
Ask therapists if they had experience treating their problem.
•
Bring a friend or family member along to an office visit.
•
Keep a written record of their treatment and emotional state.
•
Deliberately apply what they were learning in treatment to their daily lives.
Not surprisingly, CR concluded that the last step was the best predictor of a favorable outcome. Only
1 percent of respondents followed all these steps; 18 per-cent followed none.
Drugs vs. talk therapy. (2004, October). Consumer Reports, 22–29.
Mental health: Does therapy help? (1995, November). Consumer Reports, 734–739.
Seligman, M. E. P. (1995). The effectiveness of psychotherapy: The Consumer Reports study. American
Psychologist, 50, 965–974.
Lecture/Discussion Topic: Fringe Medicine
The text discusses the difficulty of answering the question, “Is psychotherapy effective?” Clients and
clinicians alike may have biased perceptions and hence selective and biased recall. Most people also
tend to make judgments that confirm their beliefs. Thus, as the text notes, “alternative therapies can
spread like wild-fire.” You can extend the discussion in class to a consideration of why many people
believe in the effectiveness of any therapy, whether it’s for a psychological or physical problem. Karl
Sabbagh’s analysis of “fringe medicine” supports the text’s argument that we need controlled research
studies to assess the effectiveness of therapy.
Practitioners of the fringe therapies (among them psychic healing, homeopathy, acupuncture) make
exorbitant claims, which are simply not supported by careful research. Still, people continue to believe. A
study by the U.S. Department of Health and Human Services indicated that 27 percent of U.S. adults
have used one or more of these questionable health treatments at some point in their lives. In fact, report
researchers, almost one-third of college or university graduates have tried at least one such treatment.
For example, people have used snake venom and bee venom as cures for arthritis (they have actually put
bees on themselves and been stung). The practice is based on the premise that some venoms reduce
inflammation. One critic suggests that people believe in it because “anything feels better” once the bees
stop stinging. A defender of the “therapy” explained the practice: Bees don’t get arthritis. Of course,
responded the critic, “Bees don’t have joints.”
Most obviously, people believe in fringe medicine because they want to. In response to the statement,
“When you have a serious health problem, it’s worth trying almost anything,” 26 percent strongly agreed
and 24 percent agreed somewhat.
As an example of how fringe medicine works, Sabbagh describes Emil J. Freireich’s tongue-in-cheek
“Experimental Plan,” which enables anyone to set him-or herself up as a therapist and is “guaranteed to
pro-duce beneficial results.” The plan has two essential requirements. The first is a treatment of some
sort; it doesn’t matter what. It can be a form of psychotherapy or some physical procedure, a type of
rubbing or hand-waving or the administration of a drug, plant, or chemical. The second requirement is that
the treatment be absolutely harmless.
Freireich shows how any such fringe technique can lead to an outcome confirming its success. The
crucial factor is the natural variability of all disease. Every disease has important periods of remission in
which the patient feels better. This is true even when there is an inexorable trend downward. Guided by
this principle, Freireich recommends that treatment be applied only after a period in which the patient has
been getting progressively worse. If treatment is applied during one of the “ups” and the patient continues
to improve, he or she can always say improvement would have occurred anyway. If the treatment is
applied when the patient is getting worse, there are four possible outcomes: (1) The patient could
improve, given the natural variability of the illness. Such an outcome immediately “proves” the treatment
is effective. (2) The disease may remain stable, proving that the treatment has arrested the problem.
(3) The patient may continue to get worse, which merely means the dosage was inadequate and must be
increased. (4) The patient may die. In this case, the treatment was obviously delayed too long and
applied too late.
When a patient improves, one must reduce the treatment. Two possible outcomes will again “prove” the
effectiveness of the therapy. If the patient continues to improve, the treatment was obviously effective. If
he or she gets worse, reducing the treatment has obviously made the disease active again.
Ruffenach, G. (1988, May 27). Unproven remedies tempt the ailing. The Wall Street Journal, p. 15.
Sabbagh, K. (1985–1986). The psychopathology of fringe medicine. The Skeptical Inquirer, 10, 154–158.
Lecture/Discussion Topic: Regression Toward the Mean
The phenomenon of regression toward the mean was first noted by Sir Francis Galton in the nineteenth
cen-tury. He observed that in any series of random events clustering around an average, an
extraordinary event is, by mere chance, most likely to be followed by an ordi-nary event. Thus, very tall
fathers are likely to have slightly shorter sons and very short fathers, somewhat taller sons. Regression
toward the mean helps explain why great movies are often followed by poor sequels, why poor
presidents often have better successors, and why extremely intelligent women tend to have slightly
duller husbands.
Paul Schaffner provides an excellent example of regression toward the mean that you can present in
class. Participants in his study assumed the role of a teacher attempting to encourage a hypothetical
student to arrive promptly for an 8:30 A.M. class. The student’s arrival time, which varied from 8:20 to 8:40
for 15 con-secutive days, was recorded on a computer. Each day the teachers could choose to praise,
reprimand, or say nothing to the student. As expected, they praised him when he was early and
reprimanded him when he was late. Unknown to the teachers, the student’s arrival time was preprogrammed and thus unrelated to the teacher’s response of the previous day. Due to regression alone,
the student’s arrival time tended to improve, that is, regress to 8:30, after being punished for being late
and to deteriorate (again by regressing to 8:30) after being praised for arriving early. Schaffner found that
70 per-cent of his teachers concluded that reprimand was more effective than praise in producing prompt
attendance by the student.
Regression toward the mean operates with regularity in sports, particularly when luck is mixed with
skill. While sports commentators recognize its effect, they often offer different explanations. Amos
Tversky notes, “Listen to the commentators at the Winter Olympics. If a ski jumper has done well on his
last jump, they say, ‘He’s under immense pressure, so he’s unlikely to do as well this time.’ If he did
poorly, they say, ‘He’s very loose and can only improve.’”
Perhaps the so-called “Sports Illustrated Jinx” can also be understood in terms of regression toward
the mean. According to sports folklore, the “Sports Illustrated Jinx” dooms teams or athletes appearing on
the cover to lose after they are featured. For example, Earvin “Magic” Johnson of the Los Angeles Lakers
graced the cover when his team was leading the NBA championship series. The Lakers then lost the title
to the Boston Celtics in seven games. Similarly, the New York Islanders were on the cover going for their
fifth straight Stanley Cup. They lost four straight to Edmonton. Tennis players and golfers seem to suffer
the most after appearing on the cover. Researchers Tim Leone and Robbie Gluckson found that the
perform-ance of these athletes fell off more than 83 percent of the time. The performance of swimmers,
skiers, foot-ball rushers, and crew members also dropped off significantly after cover appearances. At the
same time, the researchers found that baseball pitchers and teams, as well as basketball players and
teams (“Magic” Johnson being one exception), did well more than 70 percent of the time after they were
on the cover. Several observers have noted that athletes appear on the cover only after performing
unusually well. Regression toward the mean would explain their poorer subsequent performance.
McKean, K. (1985, June). Decisions, decisions.
Discover, 22–31.
Schaffner, P. (1985). Specious learning about reward and
punishment. Journal of Personality and Social
Psychology, 48, 1377–1386.
Staff. (1984, July 14). Sports Illustrated cover no jinx, say researchers. The Grand Rapids Press, p. B7.
Classroom Exercise: Regression Toward the Mean and Aspiration Level
Jerry Karylowski suggests a simple classroom demonstration of regression toward the mean, which will
work with students having no statistical background. Tell students that they will serve as your research
assistants in a study of aspiration level, a relatively stable personality trait. Briefly explain how both very
low and very high aspiration levels are maladaptive. Also tell them that you believe you have a special
psychic ability that has a therapeutic influence on those whose aspiration levels are too high or too low.
Then explain that although there are many ways to measure aspiration levels, none will be perfect. A test
score will always be a function of at least two components: (1) the true score and (2) a combination of
transient factors, such as the person’s mood, the person’s misunderstanding of some items, clerical
errors in scoring, and so on.
To illustrate, ask each student to think of three or four individuals they know well. A 6-point scale will be
used to test the participants’ aspiration levels; scores 1 and 2 will indicate a tendency for aspirations to be
lower than ability, scores 3 and 4 will indicate an appropriate aspiration level, and scores 5 and 6 will
suggest an unrealistically high aspiration level. Testing will proceed in the following way: First, each
participant will be assigned a true score on the basis of any information or intuitions students have about
him or her. Second, each participant will be assigned a transient-factors score based on die tossing (or a
number drawn out of a hat). Finally, assuming that true and transient scores are weighted equally, an
average of the two will be the simulated test score.
After students have identified their research participants and obtained the simulated test scores,
create a distribution of all scores (they will range from 1 to 6) on the chalkboard. Select two extreme
groups, the top 10 or 25 percent, and the bottom 10 or 25 percent. The top scores will be your highaspiration group, the bottom scores your low-aspiration group. Have students note the scores, perhaps
even calculating separate means for the entire distribution and for each of the extreme groups. Announce
that one day has passed since you applied your psychic treatment and that students are not to “retest”
participants that fall into the extreme groups. Tell them that unless they believe in your psychic power,
they should use the same true scores. Transient-factors scores, however, are to be assigned on the basis
of a new round of die tossing.
Finally, tabulate the post-treatment results for both the low-aspiration and the high-aspiration groups.
Students will immediately see the regression toward the mean. The post-treatment test scores for the
high-aspiration group will be lower and those for the low-aspiration group will be higher.
Karylowski, J. (1985). Regression toward the mean effect: No statistical background required. Teaching of
Psychology, 12, 229–230.
Lecture/Discussion Topic: Thinking Errors and Clinical Judgment
David Myers has described how the judgments of psy-chiatrists and clinical psychologists about the
success of therapy may reflect common errors in thinking. Consideration of these errors not only
stimulates stu-dents to think critically about the clinical process but
also serves to reinforce material from Units 2 and 7B.
A common error made by clinicians involves illu-sory correlations. Experiments conducted by Loren
and Jean Chapman found that professional clinicians per-ceived expected associations—for example,
between particular responses to Rorschach inkblots and homo-sexuality—even when the expected
associations were absent. When we believe a relationship exists, we are more likely to notice confirming
than disconfirming instances.
Clinicians’ judgments may also be contaminated by the hindsight bias and overconfidence. For
example, if a friend commits suicide, a common reaction is to think we should have been able to predict
and therefore to prevent the suicide. In retrospect, we can see the pleas for help. Thus, after a tragedy,
the hindsight bias can leave therapists feeling guilty. Conversely, Lee Ross and his colleagues have
shown how such hindsight explanations might exaggerate a clinician’s self-confidence. In one
experiment, Ross had participants read clinical case histories of people who, they were told, had
committed suicide. They were then asked to use the case history to explain the event. Later they were
informed that there actually was no available information on how the patient’s life ended. When asked to
estimate the likelihood of several possible events, including the “suicide” they had explained, suicide now
seemed quite likely. The mere activity of explaining and interpreting (which clinicians are engaged in
constantly) may itself contribute to overconfidence in one’s judgments. (Remind students of the beliefperseverance phenomenon described in Unit 7B: The act of explaining and defending a belief enables
one to understand how it might be true and thus to continue to believe it even when the data that inspired
it are discredited.)
Clients are also readily induced to give information that fulfills their clinicians’ expectations. In short,
clinicians’ judgments may reflect a self-fulfilling prophecy. Mark Snyder and William Swann found, for
example, that interviewers who questioned people to see if they had a particular trait treated them as if
they had it. The questions selected to test for extraversion could not have been better calculated to elicit
extraverted answers (“What would you do to liven things up at a party?”). Similarly, people tested for
introversion were asked questions that necessarily elicited introverted answers (“What factors make it
hard for you to open up to people?”). As a result, and as expected, targets being tested for extraversion
described a more outgoing self, and those tested for introversion revealed a more reserved self.
Additional research found that those asked “extraverted” questions not only later perceived them-selves
as more extraverted but actually became notice-ably more outgoing.
Myers, D. G. (2008). Social psychology (9th ed.). New York: McGraw-Hill.
Lecture/Discussion Topic: Therapy and the Nature of the Problem
The text concludes that therapy is most effective when the problem is specific. Those who suffer phobias
can hope for improvement; those who want to change their whole personality are unlikely to benefit from
psychotherapy alone.
Martin Seligman’s What You Can Change and What You Can’t examines the degree to which various
problems, personality types, and patterns of behavior are responsive to intervention. From those that are
easiest to those most difficult to change, Seligman suggests this continuum: panic (curable), specific
phobias (almost curable), sexual dysfunctions (marked relief), social phobia, agoraphobia, depression,
and sex role (all moderate relief or change), obsessive-compulsive disorder and sexual preferences
(moderate/mild relief or change), anger and everyday anxiety (mild/moderate relief), alcohol dependency
(mild relief), overweight (temporary change), post-traumatic stress disorder (marginal relief), sexual
orientation (probably unchangeable), and sexual identity (unchangeable).
According to Seligman, what is changeable varies with the depth of the problem. Depth has biological,
evidentiary, and power aspects.
To the degree that a problem has biological underpinnings because it is predisposed or heritable, it
will be harder to change. To the degree it is a learned habit, it is easier to change. As the text indicated
earlier, we may be more biologically prepared to fear some objects such as animals or insects because
they presented threats to our ancestors. Such fears will be harder to extinguish. Bipolar disorder, argues
Seligman, may also be highly heritable because the cycling of energy with the sea-sons, from summer
activity to winter hibernation, has an evolutionary basis.
The evidentiary aspect of a disorder deals with how easy or difficult it is to get evidence for the belief
underlying the problem as well as how difficult it is to get evidence that will disabuse one of the belief. For
example, the belief underlying post-traumatic stress disorder—that the world is a miserable, unfair
place—is easy to confirm. One only needs to read the front page of the daily newspaper. Similarly, the
thought underlying obsessive-compulsive disorders—for example, “I will die if I don’t wash my hands five
times before eating”—necessarily leads us to perform the ritual and we will never discover disconfirming
evidence. The easier a belief underlying a problem is to confirm and the more difficult it is to disconfirm,
the harder it will be to change.
Finally, the power of a belief refers to how many facts it explains. A theory has low power if it explains
only a few isolated beliefs. For example, the belief that robins are very dangerous is of low power. On the
other hand, a belief has high power if it makes sense of a great deal of our world. The belief that I am an
unlovable person or that I need to drink to get through the day has high power. To the degree that a belief
underlying a problem has high power, it will be harder to change.
Seligman, M. (1994). What you can change and what you can’t. New York: Knopf.
B. The Relative Effectiveness of Different Therapies
(pp. 654–655)
Lecture/Discussion Topic: Writing About Emotional Experiences as Therapy
In reviewing the success of many forms of psychotherapy, James Pennebaker suggests that the mere act
of disclosure may be a powerful therapeutic agent. Research indicates that writing about personally
upsetting experiences produces consistent and significant health benefits (see also Unit 8B).
Typically, participants are to asked to write for three to five consecutive days, 15 to 30 minutes
each day in response to these instructions:
For the next 3 days, I would like you to write about your very deepest thoughts and feelings about an extremely
important emotional issue that has affected you and your life. In your writing, I’d like you to really let go and explore
your very deepest emotions and thoughts. You might tie your topic to your relationships with others, including
parents, lovers, friends, or relatives; to your past, present, or your future; or to who you have been, who you would
like to be, or who you are now. You may write about the same general issues or experiences on all days of writing or
on different topics each day. All of your writing will be completely confidential. Don’t worry about spelling, sentence
structure, or grammar. The only rule is that once you begin writing, continue to do so until your time is up.
Pennebaker notes that the writing paradigm has been powerful for all age groups and ability levels.
Essays reflect a range of traumatic experiences, including lost loves, deaths, and sexual and physical
abuse. Given the opportunity, people disclose deeply personal aspects of their lives, and the vast majority
report that the writing experience was valuable and meaningful in their lives. Findings have indicated that
the disclosure is associated with significant drops in physician visits, improvement in immune function,
and positive changes in autonomic and muscular activity. Behavioral changes include improvement in
grades, faster reemployment following job loss, and lower rates of absenteeism. Self-reports indicate
reductions in distress, negative affect, and depression.
This research provides several other interesting findings: There were no differences as a function of
personality, sex, education, or ethnic background. Writing once each week over a month may be more
effective than writing four times within a single week. Talking into a microphone and writing seem to
produce comparable effects. Talking and writing about emotional experiences are both superior to writing
about superficial topics. Most interesting is the finding that social feedback seems unnecessary to
produce ben-eficial results. Essays may be placed in an anonymous-looking box with the promise that
they will not be linked to their names or even written on a “magic pad” (whereby the writing disappears
when the person lifts the plastic writing cover).
Two major explanations have been offered for the positive effects of writing. The first theory is that
not disclosing important psychological phenomena is a form of inhibition. Letting go and talking about
traumatic experiences reduces the stress of inhibition. The second explanation that receives support
from more recent research is that writing probably does more than reduce inhibition. It may produce
changes in basic cognitive and linguistic processing that prove therapeutic. For example, analyses of the
essays indicate that three linguistic factors predict improved health. First, the more the individuals used
positive emotion words, the better their subsequent health. Second, a moderate number of negative
emotion words predicted health. Both very high and very low levels of negative emotion words correlated
with poorer health. Third, and it seemed most important, an increase in both causal and insight words
over the course of writing was strongly associated with improved health. It seemed that people who
benefited from writing began with poorly organized descriptions and progressed to coherent stories by
the last day of writing. Among the research questions to be answered is whether a story can ultimately
result in the assimilation of an unexplained experience, thereby allowing the person to get on with life.
Lyubomirsky, S., Sousa, L., & Dickerhoof, R. (2006). The costs and benefits of writing, talking, and thinking
about life’s triumphs and defeats. Journal of Personality and Social Psychology, 90, 692–708.
Pennebaker, J. W. (1997). Writing about emotional experiences as a therapeutic process. Psychological
Science, 8, 162–166.
Lecture/Discussion Topic: Psychological Treatments Versus Psychotherapy
In 2001, David Barlow observes, psychology formally identified itself as a health care profession and
codified this change in the bylaws of the American Psychological Association. At the same time, Barlow
notes, there have been a number of obstacles to the inclusion of psychologists in health care systems.
These include stigma against treating the psychological aspects of physical disorders, a strong emphasis
on increased use of pharmacological treatments for most mental disorders, and questions regarding the
effectiveness of psychological interventions in chronic conditions.
However, in the last decade, research evidence shows that a new generation of powerful
psychological interventions are as effective, or even more so, than popular medical approaches in the
treatment of specific disorders. Drawing from studies in the prestigious New England Journal of Medicine
(NEJM) and the Journal of the American Medical Association (JAMA), Barlow notes that, in some cases,
psychological treatments have proven more successful than medication or routine medical care in
treating:
•
•
•
•
•
stress incontinence in women
insomnia
Gulf War veterans’ illnesses
panic disorder
depression and physical health in patients with Alzheimer’s (delaying institutionalization)
In each case, the psychological treatments were specifically tailored to the problem at hand and
took into account the patients’ specific characteristics and settings. For example, when compared with
standard medical care, a carefully crafted home-based exercise program coupled with caregiver
training in behavioral management both delayed institutionalization and improved depression in people
with Alzheimer’s. Similarly, compared with a pharmacological approach to treating insomnia in older
adults, a specially designed program that combined cognitive therapy with sleep restriction and sleep
hygiene better sustained sleep improvement. Most often, these interventions have emerged from
research in cognition and learning along with strong input from the study of social psychology and
interpersonal processes. Data suggest that these proven strategies require considerable clinical
expertise, especially for helping the more severely ill patient.
Barlow persuasively argues that in order to promote faster and more widespread dissemination of these
interventions and to solidify the identification of psychology as a health care profession, we should label
the approaches as psychological treatments. This would distinguish them from more generic
psychotherapy that is practiced by a variety of professionals and nonprofessionals. Because in-depth
training in cognitive and behavioral science and social and interpersonal processes is critical to the use of
these more sophisticated treatments, Barlow contends that a doctorate in psychology and a license are
the sine qua non for the administration of these treatments, much as a doctoral degree and license in
medicine are required to administer medical treatments for physical diseases.
Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59, 869–878.
C. Evaluating Alternative Therapies (pp. 655–657)
Lecture/Discussion Topic: Pets in Therapy
Ask your students: What effect does your pet have on your psychological well-being? Social workers and
physical therapists have used “animal-assisted” therapy for many years. Now a few psychologists have
also begun using animals in therapy (see the Close-Up in text Appendix C, p. C-5).
Previous research has found a positive relationship between pet ownership and well-being among
children, people with disabilities, and senior citizens. University of California, Los Angeles, psychologist
Judith M. Siegel and her research team reported that pets may also provide a buffer against depression
for men suffering from AIDS. They surveyed more than 1800 gay and bisexual men in three U.S. cities
who were participants in the long-term Multicenter AIDS Cohort Study con-ducted to track the AIDS
epidemic. Almost 40 percent of the men surveyed were HIV-positive and more than 10 percent had
developed AIDS. Results indicated that AIDS-infected men without pets were three times more likely to
report depression than men without AIDS. However, AIDS-infected men who owned pets were only 50
percent more likely to suffer from depression.
The benefits of pet ownership were greatest for those who had few confidants but had a close
relation-ship with their pets (e.g., sleeping in the same room). Siegel explains that pet ownership helps
reduce the isolation that can accompany AIDS. “Not only is AIDS often a stigmatizing condition, but many
of these men lose friends and companions, too,” she observes. “The attachment and tactile comfort that a
pet provides can reduce feelings of stress and loneliness.”
Murray, B. (1999, September). Pet ownership provides buffer against depression for AIDS-infected men. APA
Monitor, 6.
Siegel, J. M., Angulo, F. J., & Detels, R.,Wesch J., & Mullen A. (1999). AIDS diagnosis and depression in the
Multicenter AIDS cohort study: The ameliorating effect of pet ownership. AIDS Care, 11, 157–170.
Lecture/Discussion Topic: Trepanation
A more extreme form of alternative therapy than those described in the text is trepanation, the ancient
practice of drilling holes into the skull. Proponents claim it increases the volume of blood to the brain that
in turn fosters awareness, energy, and well-being. “More blood is available, and parts of the brain come
into function that were undernourished and starving,” claims Peter Halvorsen, a Pennsylvania jeweler
credited with introducing Americans to the practice through his Web site at www.trepan.com. “They wake
up, and feel, ‘Oh, I’m taking in new data. There is a sensory world out there that is neat.’”
A clinic in Monterey, Mexico, performs the operation for $2500, including MRI scans and a follow-up
examination. Performed solely on the skull bone, trepanation does not include puncture of the brain. The
procedure leaves about a 14-mm hole in the head that is eventually closed with scalp tissue.
William Lyons and his wife, Betty, who traveled more than 1300 miles for the surgery, claim it
increased their awareness, gave them a sudden surge in creative juices, and heightened their spirituality.
Betty claims it lifted her lifelong depression. “It was like an explosion went off in my mind and body,” she
said. “Life came back for me for the first time since I was a kid.”
Amanda Fielding, a British proponent of the procedure, performed trepanation on herself. After she
applied a local anesthetic to her scalp and taped glasses to her face to prevent blood dripping into her
eyes, she used an electric foot-operated dentist’s drill to bore a half-inch wide hole just above the hairline.
She used a mirror for guidance and had a friend film the procedure. She says she immediately felt better:
“I found it gave me more energy, lifted me up, made me more buoyant.” After the effect faded, she and
her husband traveled to Mexico and both had holes drilled in their skulls.
The procedure received national attention when ABC’s 20/20 profiled William Lyons and Peter
Halvorsen’s attempt to trepan a woman in Beryl, Utah. Before they had a chance to complete the
procedure, they were arrested and charged with practicing medicine without a license. Both pleaded
guilty and were sentenced to three years probation.
Not surprisingly, neurosurgeons say there is no scientific evidence to suggest that trepanation is
anything but dangerous. “It’s an assault, it’s not a procedure,” reported Michael Sisti, a neurosurgeon at
Columbia Presbyterian Medical Center in New York. On ABC’s 20/20, he suggested that trepanation is
really a form of self-mutilation.
Trepanning, one of the oldest forms of surgery, dating back thousands of years, may have originally been
performed to treat individuals who had suffered massive head trauma in combat. Early surgeons probably
used the procedure to remove splinters of skull bone and to relieve pressure from blood clots.
Horiuchi, V. (2001, May 6). Surgery is a real hole in the head. Grand Rapids Press, p. A-4.
Lawson, W. (2001, September 27). Cutting the cranium. ABC News. Retrieved May 14, 2002 from http://more.
abcnews.go.com/sections/science/dailynews/ trepanation000927.html).
Lecture/Discussion Topic: Autobiographies
Many psychologists argue that autobiographies by people with mental disorders can help those in
treatment. In addition to providing insight and concrete strategies, they instill hope for recovery. John C.
Norcross suggests that they offer clients a view of mental disorder from someone who has lived it.
“Scientists and educators may cry over a list of figures, but laypeople are more impressed by the dramatic
personal narrative,” Norcross argues. “Reading a narrative helps normalize and universalize what the
patient’s experiencing and can have far more powerful ramifications than just our words.”
Norcross and his colleagues asked 362 psychologists whether they had used self-help books in their
practice. Although almost 90 percent claimed that they did, only a third had used patient autobiographies.
At the same time, those who did were in agreement that they were “very” or “somewhat” helpful. When
asked to rank the top 40 autobiographies by editorial quality and helpfulness to patients, the respondents
gave the following responses (in order from first to eleventh):
1. An Unquiet Mind by K. R. Jamison (bipolar disorder)
2. Nobody Nowhere: The Autobiography of an Autistic by D. Williams (autism)
3. Darkness Visible: A Memoir of Madness by W. Styron (depression)
4. Out of Depths by A. T. Boisin (schizophrenia)
5. Girl, Interrupted by S. Kaysen (borderline personality disorder)
6. Too Much Anger, Too Many Tears by J. Gotkin and
P. Gotkin (schizophrenia)
7. Undercurrents: A Therapists Reckoning With Her Own Depression by M. Manning (depression)
8. Getting Better: Inside Alcoholics Anonymous by N. Robertson (alcoholism)
9. Am I Still Visible? A Woman’s Triumph Over Anorexia Nervosa by S. Heater (anorexia)
10. Welcome Silence: My Triumph over Schizophrenia by C. L. North (schizophrenia)
11. A Brilliant Madness: Living With Manic-Depressive Illness by P. Duke (bipolar disorder)
In addition to using these autobiographies as case studies in lecture material, you can also make
them the basis of a writing assignment, even perhaps for extra credit.
Clifford, J. S., Norcross, J. C., & Sommer, R. (1999). Autobiographies of mental health clients: Psychologists’
uses and recommendations. Professional Psychology: Research and Practice, 30, 56–59.
Norcross, J. C., Sommer, R., & Clifford, J. S. (2001). Incorporating published autobiographies into the abnormal
psychology course. Teaching of Psychology, 28, 125–128.
D. Commonalities Among Psychotherapies
(pp. 625–626)
Lecture/Discussion Topic: Evaluating Self-Help Resources
Millions of Americans, including your students, turn to self-help materials for psychological advice. Books,
magazines, Web sites, even films offer help. Some pro-vide high-quality information; others may be
misleading, inaccurate, and even harmful. Which ones are helpful, and how does one decide?
John Norcross and several coauthors provide the Authoritative Guide to Self-Help Resources in
Mental Health (Rev. ed.), an extremely helpful resource that evaluates all the major resources, organized
by topic. Based on the results of 8 national studies involving 3000 mental health professionals, the guide
addresses 36 common clinical disorders and life challenges from ADHD to weight management. The
concluding chapter provides specific “strategies for selecting self-help resources,” which include the
following:
1. Be careful not to select a self-help resource on the basis of its cover, title, or glitzy advertising
campaign. Go beyond celebrities’ testimonies, fancy ads, and the bookstore’s elaborate display.
Several of the volume’s “Not Recommended” books were, in fact, national bestsellers.
2. Select a resource that makes realistic rather than grandiose claims. Those that make grandiose claims
can be the most alluring, but most problems do not arise overnight and most can’t be solved overnight. In
short, be skeptical of anything that sounds easy, magical, and wondrous.
3. Examine the evidence reported in the self-help resource. The author’s anecdotal experiences or
personal testimonies do not count. Authors of the most effective strategies typically describe the research
and clinical evidence on which the approach is based.
4. Select self-help resources that acknowledge that problems have multiple causes and alternative
solutions. Problems are typically not so simple that they have a single cause and a simple solution.
5. Self-help resources that focus on a specific problem are better than those that claim to be a general
approach to solving all your problems. The best books don’t try to reel everyone in and don’t pre-tend to
be all things to all people. Rather, they focus on particular problems and offer specific solutions to those
problems.
6. Choose self-help resources that clearly identify their limits. Many resources promise that their advice
and products will meet every conceivable life challenge. Be wary of such claims. Good books and Web
sites will describe when their specific strategies should be used and with whom as well as when they are
not applicable or unlikely to be helpful.
7. Don’t be confused by psychobabble and slick writing. Too many authors say things like “To solve your
problem you need some high energy experiences,” “You’ve got to get in touch with your feelings,” or “You
are sending off the wrong vibes.” Such resources often regress into motivational cheerleading or
inspirational sermons.
8. Check the author’s educational and professional credentials. Is he or she a mental health profession-al
who has gone through rigorous educational training at a respected university and who has spent years
providing professional treatment?
9. Beware of authors who reject the conventional knowledge of mental health professionals. Some will
actually attack psychologists and psychiatrists as being too conservative and too concerned with scientific
evidence. Although there is nothing wrong with new techniques, there should be reliable evidence of their
effectiveness and safety.
10. Distinguish between useful information and subtle advertising. The Internet is not highly controlled
and so you cannot always distinguish between reli-able information and advertising. Check the “Who Are
We?” and “Privacy Sections” of the site. Be cautious if such information is not provided or is incomplete.
11. Use the Authoritative Guide to Self-Help Resources in Mental Health as a guide. Its recommendations
are based on the knowledge of hundreds of the most highly trained and experienced mental health
professionals in the United States.
Norcross, J. C., Santrock, J. W., Campbell, L. F., Smith,
T. P., Sommer, R., & Zuckerman, E. L. (2003).
Authoritative guide to self-help resources in mental health. (Rev. ed.). New York: Guilford.
E. Culture and Values in Psychotherapy
(pp. 626–628)
Lecture/Discussion Topic: Mental Health Values of Professional Therapists
Jay P. Jensen and Allen E. Bergin conducted a national survey of clinical psychologists, psychiatrists,
social workers, and marriage and family therapists to assess values judged relevant to the practice of
psychotherapy and important for a mentally healthy life-style. Drawing from hundreds of statements, they
finally condensed the value themes in the psychology literature into the following groupings:
1
Competent perception and expression of feelings—e.g., increase sensitivity to others’ feelings, be
open, genuine, and honest with others.
2
Freedom/autonomy/responsibility—e.g., assume responsibility for one’s actions, increase one’s
capacity for self-control, experience appropriate feelings of guilt.
3
Integration, coping, and work—e.g., develop effective strategies to cope with stress, find
fulfillment and satisfaction in work, strive for achievement.
4
Self-awareness/growth—e.g., become aware of inner potential and the ability to grow, discipline
oneself for the sake of growth.
5
Human relatedness/interpersonal and family commitment—e.g., develop the ability to give and
receive affection, be faithful to one’s marriage partner, become self-sacrificing and unselfish.
6
Self-maintenance/physical fitness—e.g., practice habits of physical health, apply self-discipline in
use of alcohol, tobacco, and drugs.
7
Mature values—e.g., have a sense of purpose in living, regulate behavior by applying principles
and ideals.
8
Forgiveness—e.g., forgive others who have hurt you, make restitution for one’s own negative
influence.
9. Regulated sexual fulfillment—e.g., understand that sexual impulses are a natural part of oneself, have
sexual relations exclusively in marriage, prefer a heterosexual sex relationship.
10. Spirituality/religiosity—e.g., seek strength through communion with a higher power, actively
participate in a religious affiliation.
Hundreds of mental health professionals were asked to rate the importance of each value for a positive,
mentally healthy life-style and to indicate the pro-portion of clients for whom the value was considered
important in the process of psychotherapy. Contrary to the notion that therapists should be neutral on
values, the survey results indicated that there was considerable agreement that certain basic values are
important for mentally healthy life-styles as well as for guiding and evaluating psychotherapy. In fact,
there was surprising consensus on many of the value themes with broad endorsement of the first eight
value themes.
Sex and religion were two themes that elicited considerable disagreement. For example, “having sexual
relations exclusively within marriage” and “preferring a heterosexual relationship” received “high” or
“medium” support from only 49 and 43 percent of the mental health professionals, respectively. “Seeking
strength through communion with a higher power” and “actively participating in a religious affiliation”
received support from only 34 and 28 percent, respectively.
In discussing these results, you might ask students to reflect on whether they think there would be any
differences from respondents in other cultures or, if the study were repeated today (it was published in
1988), in the United States.
The authors conclude by raising the important question of how therapists should approach their clients’
values and life-styles, particularly if the therapist’s intent is to modify them. First, client self-determination
must be respected. Therapists cannot improve mental health by undermining autonomy, which would be
the case in any force-feeding of values. Therapists have to decide how best to optimize their clients’
functioning and only then collaborate with their clients in arriving at goals that will facilitate change.
Second, therapists must be explicit. Being open about values protects clients by making the agenda and
alter-natives clear and makes it less likely that clients will be manipulated by subtle shaping.
Jensen, J. P., & Bergin, A. E. (1988). Mental health values of professional therapists: A national interdisciplinary
survey. Professional Psychology: Research and Practice, 19, 290–297. Copyright 1988. Reprinted by
permission of the authors.
Student Project: Applying the Major Therapies
To conclude discussion of the psychological therapies, present students with a case study of a
psychological disorder and ask them to describe how each major therapy—psychoanalysis, humanistic
therapy, behavior therapy, and cognitive therapy—would approach the client. You can present a new
case of your own or refer students back to one of the examples given in the previous unit, e.g., the case
of Marc (obsessive-compulsive disorder), Greta (depression), or Stuart (schizophrenia). You can make
this an individual writing project or divide your class into small groups to complete the assignment.
Conclude the exercise with a full-class discussion of how different therapists would approach the case.
IV. The Biomedical Therapies (pp. 628–637)
A. Drug Therapies (pp. 628–632)
Lecture/Discussion Topic: SSRI Antidepressants
Introduced in 1987, Prozac became the world’s most widely prescribed antidepressant. In fall 2001, it fell
to third place when it lost market exclusivity to generic competition. It’s cousins Zoloft and Paxil became
close competitors for first place. Curiously, research suggests that these SSRI drugs show virtually no
difference in effectiveness, safety, and side effect profile. Pharmaceutical commercials for the drugs
increased dramatically after the September 11, 2001, terrorist attacks. In fact, Pfizer, the world’s largest
pharmaceutical company, spent $5.6 million promoting the benefits of Zoloft in treating post-traumatic
stress disorder during October 2001.
In the past, antidepressants have been one of two basic types: tricyclics or monoamine oxidase
inhibitors (MAOIs). Both strengthen the action of serotonin and norepinephrine, two of the chemicals that
transmit impulses through the nervous system. The tricyclics work by blocking the reabsorption of the
messengers by the nerve cells that release them. The MAOIs interfere with the enzymes that break the
messengers down. Although the SSRIs work like the tricyclics—that is, they keep a neurotransmitter in
circulation by blocking reabsorption—they work exclusively on serotonin, not norepinephrine. “Instead of
using a shotgun, you’re using a bullet,” observes psychiatrist James Halikas of the University of
Minnesota.
The SSRIs’ advantage is not that they are inherent-ly more effective in treating depression but rather
that they are easier to prescribe and have fewer side effects. They also have a broader range of uses
than competing drugs.
SSRIs’ side effects have included headaches, nausea, insomnia, and weight loss. However, these
are far less serious than the low blood pressure, heart disturbances, blurred vision, and weight gain
produced by the older drugs. People unable to tolerate the tricyclics or MAOIs are successfully taking
the SSRIs.
Doctors are now using the drugs not only as a treatment for depression but also to treat anxiety,
obsessive-compulsive disorder, and post-traumatic stress disorder. Neurologist Ruth Brunn explains,
“Some people respond to one and not the other. But most are helped by one or the other. The new drugs
have absolutely revolutionized treatment of this disorder.”
Cowley, G., et al. (1990, March 26). The promise of Prozac. Newsweek, 38–41.
Rosack, J. (2002, March 1). “Drug makers find September 11 a marketing opportunity,” and “SSRIs show little
difference as first-line treatment,” Psychiatric News, 9 and 25.
Lecture/Discussion Topic: Cosmetic Psychopharmacology
Prozac was labeled the wonder drug of the 1990s. As noted above, it not only treats depression
effectively, it works in alleviating the symptoms of other psychological disorders. In Listening to Prozac,
Peter Kramer describes the global effects of the drug, which makes some people feel “better than well.” In
describing the drug’s ability to alter personality style, he tells of trans-formed lives in which patterns of
withdrawal, compulsiveness, and timidity are replaced with radically different and personally satisfying
ways of interacting with the world. Overall self-image improves, energy levels increase dramatically, and
greater social popularity is achieved. People experience greater success and satisfaction in most every
aspect of life.
Kramer raises a number of important issues that make excellent discussion-starters for class. For
example, he asks how proper it is to prescribe Prozac to those who suffer no specific psychological
disorder but who want to function more effectively in their personal and social lives. Is this not “cosmetic
psychopharmacology,” akin to a psychological nose job? Kramer notes that our discomfort may arise in
part from our belief that it is all very well for drugs to do small things—for example, to induce sleep, allay
anxiety, reduce depression—but not to transform entire lives. For a drug to have such a pronounced
effect is inherently unnatural, unsafe, even uncanny. While we might respond to the dilemma by saying let
each person choose, to the degree that Prozac becomes widely used, it ups the stakes with respect to
social competition in much the same manner that steroids up the stakes in Olympic competition. While
people can choose not to take the drug, where does that place them in a culture in which cosmetic
psychopharmacology stands as the norm? At best it becomes “free choice under pressure.”
Prozac (as well as its cousins Zoloft and Paxil) is clearly effective in reducing negative emotions. For
example, it seems to possess the potential to obviate grief. Isn’t it wonderful to find relief from debilitating
grief and to become able once again to live one’s life? Or is grief natural and even healthy? More
generally, is it possible that transforming medication interferes with the process of self-examination that
often accompanies our negative emotions?
Kramer also ponders whether Prozac serves to enforce arbitrary cultural values. He notes the
popularity of Valium as a treatment choice for anxious women during the 1950s and 1960s. Many would
argue that Valium helped to keep them in their place. Yet anxiety and discontent may have been
appropriate responses for women of that era, given the restrictive expectations placed upon them. Now
that women are expected to be active, productive, and assertive, Prozac may paradoxically serve the
same function, that of molding them to the current cultural ideal.
Kramer, P. (1993). Listening to Prozac: A psychiatrist explores antidepressant drugs and the remaking of the
self. New York: Viking.
Lecture/Discussion Topic: A Pill for Stage Fright (Anxiety)
Michael Skoler reports that Inderal, a heart medication (known generically as propranolol), is the
antianxiety drug for intellectuals. Unlike tranquilizers, Inderal does not cloud the mind or impair physical
coordination. Professional musicians, lawyers, undergraduate students, and even physicians now take
this beta blocker before important presentations or tests. The FDA has not approved Inderal specifically
for anxiety, but when a drug has been approved for one condition, physicians can legally prescribe it for
others.
In the early 1960s, beta blockers were approved to treat high blood pressure and hardening of the
arteries. Patients who took the medication experienced a pleas-ant side effect: The drugs kept them
calm in stressful situations, which should not have been surprising because beta blockers reduce the
symptoms that often accompany nervousness. That is, they keep blood pres-sure from rising and the
heart from racing by blocking the chemical messengers that produce these changes.
In a test of the effectiveness of Inderal, professional musicians were given either a sugar pill or
Inderal before performing for three judges and a small audience. The musicians who took Inderal
reported feeling more in control and their heart rates were slow and even (without the drug their heart
rates were 40 beats a minute faster). More important, the judges evaluated their performances as
significantly better. A 1987 survey indicated that 27 percent of professional musicians had used the drug.
Psychiatrists estimate the number is much higher.
Inderal has also been tested with high school students who freeze when they take the SAT. Twenty-five
students took the test twice, using the beta blocker the second time. Combined verbal and math scores
went up an average of 120 points. Normally, a combined score goes up only 22 points. After these results
were reported in the press, dozens of parents called asking for the name of the drug and correct dosage,
so that their doctors could prescribe it for their children. “We could easily teach students that the only way
they can face a test is to take an Inderal tablet,” says Harris Faigel, who is conducting the research. “It
makes me wonder whether we should continue the study.”
Psychologist Mark Siegert believes Inderal is useful for helping people whose stage fright is primarily a
physical problem. Some people’s bodies simply overreact to fear. He is concerned, however, that others
will view the drug as “a way to perform free of anxiety.” And, he concludes, “In my experience anxiety is
some-thing we have to live with.”
The controversy surrounding the use of Inderal by musicians is reflected in the case of Ruth Ann McClain,
who taught flute at Rhodes College. She was fired after recommending the drug to adult students afflicted
with performance anxiety. College officials claimed that recommending drugs fell outside the studentinstructor relationship. They also charged that Ms. McClain, who had taught at Rhodes for 11 years, had
asked a doctor for medication for her students. McClain said she mere-ly recommended that the students
consult a physician about obtaining a prescription. “If I am looking out for the welfare of my students,” she
stated, “I cannot in good conscience not tell them about beta blockers.”
Some critics have also questioned the ethics of better performance through chemistry. For example, in
auditions, which are even more nerve-racking than regular performances, do those on drugs have an
unfair advantage over those who do not? Might drug testing apply to performers, just as it does to some
athletes and to job applicants at some companies? Some wonder whether professional musicians might
some day join professional athletes in scandals involving performance-enhancing drugs. Obviously, beta
blockers such as Inderal differ significantly from steroids, which use testosterone to increase muscle
mass, strength, and speed. One physician noted that, rather than enhance, Inderal enables by removing
debilitating symptoms. It does not improve tone or technique, nor does it compensate for inadequate
preparation.
Skoler, M. (1988, March/April). Upstaging fright with a pill. Hippocrates, 26–28.
Tindall, B. (2004, October 17). Better playing through chemistry. New York Times. Retrieved from
http://query.nytimes.com/gst/fullpage.html?res=940DE7DC1E3BF934A25753C1A9629C8B63.
B. Brain Stimulation (pp. 632–635)
Lecture/Discussion Topic: Electroconvulsive Therapy
Harold Sackeim has attempted to correct misconceptions surrounding ECT and to prove that it is a valid,
even life-saving option. While the public often believes that the treatment is only imposed on troublesome
or unwilling patients, such as those portrayed in Ken Kesey’s One Flew Over the Cuckoo’s Nest, the
typical ECT patient is White, female, middle-aged, and from a middle-to-upper-income background. She
usually receives treatment in a private or university hospital after drug therapy has proved ineffective.
Because the therapy is a relatively expensive and complicated procedure, requiring specially trained
psychiatrists, anesthesiologists, and nurses, it is used far less extensively in public hospitals.
The aim of ECT is to produce a seizure in the brain, similar to what occurs spontaneously in some
types of epilepsy. In fact, research suggests that without a seizure, ECT is ineffective. A small electric
current passes through two electrodes placed on the patient’s head. Only a portion of this current reaches
the brain because most of it is deflected by the skull. Since muscle relaxants may interfere with breathing,
an anesthesiologist administers oxygen. The muscle relaxants often block all outward signs of a seizure,
and so the patient’s brain waves must be monitored. The procedure takes about 5 minutes, and
complications are rare. Since patients sleep through the therapy, it should come as no surprise that in
one study, 82 percent rated ECT as equally or no more upsetting than going to the dentist.
Irwin and Barbara Sarason review the important improvements that have been made in ECT since it
was first introduced and that have greatly improved its safety. For example, the intensity of the electrical
charge has been cut in half and its duration has been reduced from one second to one-twenty-fifth of a
second. The sessions have been reduced from three a day to no more than three a week. In addition, the
length of treatment has been decreased from more than 20 sessions to typically 10 or fewer. In contrast
to earlier treatments, both anesthetics and muscle relaxants are now used and brain waves and the
electrical functioning of the heart are monitored through EEG and EKG. Whereas electrodes were
formerly placed on both sides of the head, they are now placed on the nondominant side only.
Researchers in Iowa found that more than 10 per-cent of untreated patients diagnosed as suffering
from major depressive disorder died within three years. Although some were suicide victims, 75 percent
of those who died did so as a result of illnesses such as heart attack and cancer. Only 2 percent of
patients who received ECT died within three years.
Sackeim provides a case history to illustrate ECT’s potential effectiveness. Anna, a 36-year-old
teacher and mother of two, had a history of recurrent depression and had been in psychotherapy for
several years. She also had been treated with antidepressant drugs, which were ineffective. Finally
hospitalized, Anna described life as a “living hell.” She slept poorly, had little appetite, and experienced
significant weight loss. Her concentration was so poor she could barely read a newspaper headline.
Obsessed with the notion that she had ruined her children’s lives, she threatened to kill herself. With her
consent, psychiatrists began ECT. After five treatments, she had completely recovered and returned to
her family and job.
How does ECT compare with alternative treatments for depression? When compared with antidepressant
drugs, ECT has proved either as effective or more effective. Overall, Sackeim reports, it can help 70 to 80
percent of all people with major depressive disorder. He cautions, though, that it should not be viewed as
a cure. Patients, particularly those with a history of recurrent depression, are likely to relapse unless they
receive some form of medication or therapy following ECT.
When compared with other treatments for anxiety and personality disorders, ECT has been found to be of
little value. Except in cases of catatonia, there is little evidence that the treatment is effective with
schizophrenia patients. At one time, some psychiatrists wrongly believed that because schizophrenia was
rare in epileptics, seizures might protect against schizophrenia. As a result, thousands of schizophrenia
patients throughout the world were treated with ECT.
Sackeim, H. (1985, June). The case for ECT. Psychology Today, 36–40.
Sarason, I., & Sarason, B. (2005). Abnormal psychology (11th ed.). Upper Saddle River, NJ: Prentice Hall.
C. Psychosurgery (pp. 635–636)
Lecture/Discussion Topic: Cingulotomy
By 1949, when Egas Moniz won a Nobel Prize for developing the lobotomy, tens of thousands had been
lobotomized—alcohol abusers, criminals, and people with mental retardation, including Rosemary
Kennedy, sister of the future president. During the 1950s, calming drugs became available and
psychosurgery was largely abandoned. The text notes that lobotomies are no longer performed and that
other psychosurgery is used only in extreme cases. For the most part, psychosurgery has become taboo,
even though refinements targeting very limited areas in the brain are now much safer. Neurosurgeons
perform operations at the risk of being picketed. Students may be interested in learning that Moniz
himself was shot and left partially paralyzed by one of his lobotomized patients.
One notable exception is a procedure known as cingulotomy, which has been performed at
Massachusetts General Hospital. Bearing little relation to the lobotomy, the procedure involves passing
an electrode needle through two small holes in the skull and searing a tiny lesion in the cingulum, a
bundle of nerve fibers linking the emotional centers of the brain with the thought centers in the cortex.
Since 1962, about 700 patients have received cingulotomies, averaging about 20 operations annually.
Used primarily in the treatment of obsessive-compulsive disorder, certain phobias, and depression, the
surgery is offered only to those who have been ill for years and, in many cases, are at risk for suicide. In
addition, patients must provide extensive documentation that they have tried every other available form of
thera-py and drug treatment. No surgery is ever performed without the patient’s informed consent.
Although case reports indicate extraordinary turn-arounds for some very sick people, experts do
not agree on the overall success rate of this surgery. The hospital’s chief surgeon G. Rees Cosgrove puts
the improvement rate as high as 60 to 70 percent for depression, some-what less for obsessivecompulsive disorder. All agree, however, that the procedure is relatively benign, causing none of the
disastrous side effects associated with lobotomies. A new surgical tool called the Gamma knife permits
the procedure to be performed without piercing the skull. It shoots hundreds of beams of radiation from
different angles at the target site in the brain. Although no single beam damages tissue, where the beams
converge, a lesion is created.
Beck, M. (1990, March 26). Beyond lobotomies. Newsweek,, 44.
D. Therapeutic Life-Style Change (pp. 636–637)
Lecture/Discussion Topic: Therapeutic Life-Style Change
You can readily extend the unit’s brief treatment of therapeutic life-style change, including more specific
recommendations to students on how they might implement each of the six crucial components. At their
helpful Web site (www.psych.ku.edu/tlc), Stephen Ilardi and his colleagues include the following advice:
1
Aerobic exercise: Aerobic exercise is anything— running, walking fast, biking, or playing
basketball, for example—that gets your heart rate elevated to about 120 to 160 beats per minute.
Anaerobic exercise (such as yoga or weightlifting) is better than nothing, but aerobic exercise produces
the strongest antidepressant effects. Many people find that a regular exercise routine and an exercise
partner help them remain motivated.
2
Adequate sleep: Go to sleep and wake up at the same time every day. Prepare yourself by
having a “bedtime ritual.” Dim the lights, turn off the TV and computer, and put on your PJs. Engage in a
quiet activity such as reading. Avoid caffeine and alcohol several hours before you plan to go to bed.
1
Light exposure: If you cannot go outside, get light exposure from a special light box that emits
10,000 lux. A good one costs about $170 (www.Light TherapyProducts.com). Try to get light exposure at
the same time each day. Some prefer to sit by it while they eat breakfast and read the paper. Others like
it on while they read or study in the evening. Experiment to see what works best for you. Try your best to
avoid missing a day since this is some-thing that will only work for you cumulatively if you are consistent.
2
Social connection: Recognize that as you become more depressed, you are less motivated to
seek out others for socializing. Spend as much time as possible with others. This is a powerful way to
distract yourself from rumination.
3
Anti-rumination: Rumination is a habit that many depressed people fall victim to as their negative
thoughts spiral out of control. Put a stop to it immediately. Call a friend, exercise, write down the negative
thoughts in a journal, or engage in some pleasant activity (e.g., knitting, reading, or another favorite
hobby).
4
Nutritional supplements: You can buy omega-3 fatty acid supplements at a drugstore or health
food store. Look for a brand that gives you 1000 mg of EPA and 500 mg of DHA per day. This is the
amount that has been shown to be beneficial to people with depression. These can be taken even if you
are on an antidepressant. To avoid aftertaste, freeze the pills and take them right before a meal. Some
people prefer to take the supplements in liquid form.
In presenting these specific recommendations, you might emphasize that Ilardi’s goal is to enable people
to fight depression without prescription drugs whenever possible. According to Ilardi, research indicates
that these behavioral changes produce the same beneficial brain change that come from medication but
without the risks and side effects. Moreover, many people who take drugs such as Prozac or Zoloft gain
relief simply because of a placebo effect. More recent studies (as reported by Ilardi to Katie Greene) also
show that some medications could increase the risk of suicidal behavior. Impulsive violent behavior,
sexual side effects, and even emotional numbing are also potential risks. Finally, “As soon as they stop
taking the medication,” observes Ilardi, they have about a 50/50 chance of having the depression return in
under a year.”
Greene, K. (2005). Change your life, change your mind. Kansas Alumni Magazine, 2, 23–27.
Ilardi S. S., Karwoski, L., Lehman, K. A., Stites, B. A., & Steidtmann, D. (2007). We were never designed for
this: The depression epidemic and the promise of thera-peutic lifestyle change. Unpublished manuscript,
University of Kansas.
V. Preventing Psychological Disorders
(pp. 637–638)
Lecture/Discussion Topic: Positive Psychotherapy
You can extend the discussion of preventing psychological disorders to consideration of Martin
Seligman’s positive psychotherapy (PPT) that emphasizes human flourishing (see also text Unit 10). In
early research, PPT was combined with more traditional therapeutic approaches in the treatment of
depression. Clearly, however, PPT strategies can be applied more generally in preventing psychological
disorder.
PPT contrasts with standard therapies in its emphasis on building positive emotions, character
strengths, and purpose in life. Depression in particular seems to be marked by a lack of positive emotion,
absence of engagement, and lack of felt meaning.
The exercises that Seligman and his research team utilize include the following:
1
Using your strengths. Participants complete a questionnaire assessing their top five strengths and
then consider specific ways of using those strengths in everyday life.
2
Three Good Things/Blessings: Each evening participants write down three good things that
happened in the course of the day and why they think they happened.
3
Obituary/Biography: Participants anticipate passing away after living a fruitful and satisfying life
and then write a brief essay summarizing what they would like to be remembered for most.
4
Gratitude Visit: Participants think of someone to whom they are grateful, compose a letter
describing their gratitude, and read the letter by phone or in person.
5
Active/Constructive Responding: At least once a day, participants react in a visibly positive and
enthusiastic way to good news from someone else.
6
Savoring: Once a day, participants take time to enjoy something that they usually rush through
(e.g., eating a meal, taking a shower). When it’s over, they write down what they did, how they did it
differently, and how it felt compared with when they rush through it.
Two preliminary studies by Seligman and his research team suggest that PPT (using the elements
just described) is effective. In the first study, PPT delivered to groups significantly decreased levels of
mild-to-moderate depression through a 1-year follow-up. In a second study, PPT delivered to outpatients
suffering major depressive disorder proved more effective than “treatment as usual” (including cognitivebehavioral therapy) and “treatment as usual plus medication.”
Seligman, M. E. P., Rashid, T., & Parks, A. C. (2006). Positive psychotherapy. American Psychologist, 61,
774–788.
Lecture/Discussion Topic: From a Disease Focus to a Wellness Model
Emory Cowen, former professor of psychology and psychiatry at the University of Rochester and director
of the university’s Center for Community Study, argued that we must replace the pervasive “disease”
model in psychology with a “wellness” model. We must shift from emphasizing people’s weaknesses to
shoring up their strengths. The task will not be easy, he suggests, for even the mental health field “simply
and naturally thinks sick more, and long before, it thinks well.”
Four specific concepts currently being researched and tested in programs such as Head Start and the
Perry Preschool Project (which target inner-city children from high-risk families) illustrate what Cowen
means by a new emphasis on wellness.
The first is teaching competence. This refers to both practical skills, such as those necessary to do a job
well, and social skills, such as the ability to communicate and control anger. “The presence of these
skills,” says Cowen, “relates to wellness, and their absence to maladaptation.” Although acquiring
competence is life-long, the best time to lay the foundation is in childhood.
Another concept is resilience, or the ability to with-stand pressure and emerge stronger for it. Cowen
advocates examining in greater detail youngsters who live “in the chronic shadow of what psychologist
Norman Garmezy so aptly called ‘stressors of marked gravity.’” Studying those who thrive in this
environment could help others living under chronically stressful conditions.
Two socially oriented concepts are also important in Cowen’s model. One is social-system modification,
that is, helping foster environments that promote wellness. Institutions such as schools, churches, and the
workplace are especially important to target because they are rarely neutral in their impact on people.
“Whereas some act coincidentally to enhance wellness,” says Cowen, “others, oblivious to incidental
outcome effects, may pose unintended obstacles to wellness.”
The other social concept is empowerment. For many people, the roots of maladaptation, or problems
in living, reside less in personal failings than in de facto aspects of the macrosystem that deprive them of
power, justice, and opportunity. A major goal then is to pro-mote policies and conditions that enable
people to gain control over their lives on the assumption that this will reduce problems in living and
enhance wellness.
Cowen, E. L., Hightower, A. D., Pedro-Carroll, J. L., Work, W. C., Wyman, P. A., & Haffey, W. G. (1996). Schoolbased prevention for children at risk: The primary mental health project. Washington, DC: American
Psychological Association.
De Angelis, T. (1990, December). Should wellness model replace disease focus? APA Monitor, 30.
Lecture/Discussion Topic: Principles of Effective Prevention Programs
In a review of reviews, Maury Nation and his colleagues sought to identify successful prevention
strategies for addressing problems of substance abuse, risky sexual behavior, school failure, and juvenile
delinquency. They identified nine characteristics that were consistently associated with effective
programs.
1
Comprehensive: Each strategy used multiple interventions across several critical domains—e.g.,
family, peers, community—that affected the development and perpetuation of the problems to be
prevented.
2
Varied teaching methods: These methods all focused on increasing the patient’s awareness and
understanding of the problem behaviors as well as on acquiring and enhancing relevant skills.
3
Sufficient dosage: Programs provided enough intervention to produce the desired effects and
provided necessary follow-up to maintain the results of the program.
4
Theory-driven: Programs had a theoretical justification, were based on accurate information, and
were supported by empirical research.
5
Positive relationships: Programs provided exposure to adults and peers in a way that fostered
strong interpersonal connections and support.
6
Appropriately timed: Programs were started early enough to have an effect on the development of
the problem behavior and were sensitive to the developmental needs of the participants.
7
Socioculturally relevant: Programs were sensitive to the community and cultural norms of the
participants and made deliberate efforts to include the tar-get group in program planning and
implementation.
8
Outcome evaluation: Programs had clear goals and objectives and made an attempt to
systematically document their results relative to the goals.
9
Well-trained staff: Program staff supported the pro-gram and were trained in the implementation
of the intervention.
The researchers conclude that their review offers important guidelines for conceptualizing and
develop-ing future prevention strategies. Moreover, they argue for “multiple-problem” prevention
programs because at-risk children tend to be vulnerable to a variety of disorders as a result of
dysfunctional families, neighbor-hoods, schools, and peer relationships.
Nation, M., et al. (2003). What works in prevention: Principles of effective prevention programs. American
Psychologist, 58, 449–456.
Classroom Exercise: The Personal Growth Initiative Scale (PGIS)
Christine Robitschek’s (1998) Personal Growth Initiative Scale (PGIS), Handout 13–12, provides an
excellent conclusion to this unit and, specifically, to the topic of preventing psychological disorder.
Personal growth, suggests Robitschek, is a person’s active, intentional involvement in changing and
developing. Growth, she suggests, must be an intentional process.
To obtain a total score, students add the numbers they gave in response to each statement. PGIS scores
range from 0 to 45. High scorers (above 22.5, the mid-point) recognize and capitalize on opportunities for
personal change. More important, they search out and create situations that will foster their growth. In
contrast, those with low scores actively avoid situations that challenge them to grow.
PGIS scores seem to have a strong positive relationship to psychological well-being and a negative
relationship to psychological distress. So the higher the PGIS score, the less psychological distress the
person seems to feel. Robitschek and her colleagues are presently examining whether PGI might also
defend against distress by leading people to seek help earlier— when they first experience negative
events—thus reducing the extent and effects of stress. PGIS scores are positively linked to
assertiveness, internal locus of control, and instrumentality (knowing how to reach important goals). No
differences in scores are found between men and women or between ethnic minority and majority groups.
Robitschek, C. (1998). Personal growth initiative: The construct and its measure. Measurement and Evaluation
in Counseling and Development, 30, 183–198.
Robitschek, C. (1999). Further validation of the Personal Growth Initiative Scale. Measurement and Evaluation
in Counseling and Development, 31, 197–210.
Robitschek, C., & Cook, S. W. (1999). The influence of personal growth initiative and coping styles on career
exploration and vocational identity. Journal of Vocational Behavior, 54, 127–141.
Whittaker, A. E., & Robitschek, C. (2001). Multidimen-sional family functioning as predictors of personal growth
initiative. Journal of Counseling Psychology, 48, 420–427.
PLEASE NOTE: Due to loss of formatting, the Handouts are only available in
Adobe