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CHAPTER 2

CURRENT PARADIGMS IN PSYCHOPATHOLOGY

CHAPTER SYNOPSIS

Science is a human enterprise, and scientific inquiry is limited by scientists’ human limitations and by the limited state of our knowledge: people see only what they are able to see, and other phenomena go undetected because scientists can discover things only if they already have some general idea about them. A paradigm is a conceptual framework or general perspective. Because the paradigm within which scientists and clinicians work helps to shape what they investigate and find, understanding paradigms helps us to appreciate subjective influences that may affect their work. Several major paradigms are current in the study of psychopathology and therapy:

1. Genetic. 2. Neuroscience. 3. Psychodynamic. 4. Cognitive Behavioral.

The choice of a paradigm has important consequences for the way in which abnormal behavior is defined, investigated, and treated.

The Genetic Paradigm

The genetic paradigm focuses on questions such as whether certain disorders are heritable and, if so, what is actually inherited. Heritability is a population statistic, not a metric of the likelihood a particular person will inherit a disorder. Environmental effects can be classified as shared and nonshared. Molecular genetics studies isolate particular genes and gene polymorphisms that may be involved in psychopathology.

Behavior genetics is the study of the degree to which genes and environmental factors influence behavior. The total genetic makeup of an individual, consisting of inherited genes, is referred to as the genotype (physical sequence of DNA); the genotype cannot be observed outwardly. In contrast, the totality of observable, behavioral characteristics, such as level of anxiety, is referred to as the phenotype.

Molecular genetics studies seek to find out what exactly is heritable by identifying particular genes and their functions. Different forms of the same gene are called alleles. A genetic polymorphism refers to a difference in DNA sequence on a gene that has occurred in a population.

Research has emphasized the importance of gene-environment interactions. Genes do their work via the environment in most cases. Recent examples of genetic influence being manifested 2

only under certain environmental conditions (e.g., poverty and IQ; early maltreatment and depression) make clear that we must not look just for the genes associated with mental illness, but also for the conditions under which these genes may be expressed.

The Neuroscience Paradigm

The neuroscience paradigm is concerned with the ways in which the brain contributes to psychopathology. Each neuron has four major parts; the cell body, dendrites, axons, and terminal buttons. The gap between adjacent neurons is called the synapse. Neurotransmitters such as serotonin, norepinephrine, dopamine, and GABA have been implicated in a number of disorders. Glial cells interact with neurons and control how neurons work. They have also been implicated in disorders such as dementia and schizophrenia. A number of different brain areas are also a focus of research. The autonomic nervous system, which includes the sympathetic and parasympathetic nervous systems, is also implicated in the manifestations of some disorders. The sympathetic nervous system prepares us for sudden activity and stress. The parasympathetic helps us to calm down, though these distinctions are not always so clear-cut. The brain itself includes a variety of structures important for mental functioning, such as the prefrontal cortex, hippocampus, hypothalamus, and the amydgala. As part of the neuroendocrine system, the HPA axis is responsible for the body’s response to stress and thus is relevant for several stress-related disorders. Biological treatments, primarily medications, are effective treatments for different disorders, but these treatments are not necessarily treating the cause of the problems. Although the brain plays an important role in our understanding of the causes of psychopathology, we must be careful to avoid reductionism.

The Cognitive Behavioral Paradigm

The cognitive behavioral paradigm reflects influences from behavior therapy and cognitive science. Treatment techniques designed to alter the consequences or reinforcers of a behavior, such as in time-out or a token economy, are still used today. Exposure is a key component to cognitive behavioral treatments of anxiety. Cognitive science focuses on concepts such as schemas (a network of accumulated knowledge or set), attention, and memory, and these concepts are part of cognitive behavioral theories and treatments of psychopathology. Cognitive behavior therapy uses behavior therapy techniques and cognitive restructuring. Aaron Beck and Albert Ellis are two influential cognitive behavior therapists. The boundary between what is behavioral and what is cognitive is not always so clear in the cognitive behavioral paradigm.

The Psychodynamic Paradigm

The psychodynamic paradigm derives from the work of Freud and his followers. The contribution of the paradigm has been primarily in treatment. Contemporary psychodynamic theories include ego analysis, which introduced the concept of pathogenic beliefs; object relations, which stresses the importance of relationships; and its offshoot, attachment theory, which emphasizes the role of attachment styles in infancy through adulthood. The theories of Freud and other psychodynamic theorists do not lend themselves to systematic study, which has limited their acceptance by some in the field. However, more contemporary psychodynamic researchers along with researchers in other fields, such as cognitive neuroscience and social psychology, have generated a body of empirical research on concepts such as the unconscious and interpersonal relationships. For example, research on implicit memory and the relational self has promoted acceptance of the ideas of unconscious influences on behavior and the role of the self in relation to others. Brief psychodynamic therapy and interpersonal therapy are two contemporary psychotherapies that are based in psychodynamic theory. Although Freud’s early work is often criticized, this paradigm has been influential in the study of psychopathology in that it has made clear the importance of early experiences, the notion that we can do things 3

without conscious awareness, and the point that the causes of behavior are not always obvious.

Factors that Cut Across the Paradigms

Emotion plays a prominent role in many disorders, but the ways in which emotions can be disrupted varies quite a bit. Emotions guide our behavior and help us to respond to problems or challenges in our environment. It is important to distinguish among components of emotion that may be disrupted, including expression, experience, and physiology. In addition, mood can be distinguished from emotion. The concept of ideal affect points to important cultural differences in emotion that may be important for psychopathology. Psychological disorders have different types of emotion disturbances, and thus it is important to consider which of the emotion components are affected. In some disorders, all emotion components may be disrupted, whereas in others, just one might be problematic. Emotion is an important focus in the paradigms.

Sociocultural factors, including culture, ethnicity, gender, poverty, social support, and relationships are also important factors in the study of psychopathology. Some disorders appear to be universal across cultures, like schizophrenia or anxiety, yet their manifestations may differ somewhat and the ways in which society regards them may also differ. Other disorders, like eating disorders or hikikomori, may be specific to particular cultures. Some disorders are more frequently diagnosed in some ethnic groups compared to others. (See Table 2.1). It is not clear whether this reflects a true difference in the presence of disorder or perhaps a bias on the part of diagnosticians. Social relationships can be important buffers against stress and have benefits for physical and mental health. Consequently, it is important that clinicians help clients build and maintain healthy social relationships. This goal is accomplished through a number of different approaches, including couples therapy, family therapy, and interpersonal therapy. Couples therapy and family therapy can be used to strengthen social relationships and improve healthy communication. Interpersonal Therapy aims to help clients strengthen their interpersonal relationships by helping clients generate solutions to interpersonal problems. Current research is also examining whether risk factors associated with various disorders differ for men and women. Sociocultural factors have recently become the focus of people working in the other paradigms, and this trend will continue.

Diathesis–Stress: An Integrative Paradigm

Because each paradigm seems to have something to offer to our understanding of mental disorders, it is important to develop more integrative paradigms. The diathesis-stress paradigm, which integrates several points of view, assumes that people are predisposed to react adversely to environmental stressors. The diathesis may be genetic, neurobiological, or psychological and may be caused by early-childhood experiences, genetically influenced personality traits, or sociocultural influences, among other things.

LEARNING GOALS

1. Be able to describe the essentials of the genetic, neuroscience, psychodynamic, and cognitive behavioral paradigms. 2. Be able to describe the concept of emotion and how it may be relevant to psychopathology. 4

3. Be able to explain how culture, ethnicity, and social factors figure into the study and treatment of psychopathology. 4. Be able to recognize the limits of adopting any one paradigm and the importance of integration across multiple levels of analysis, as in the diathesis-stress integrative paradigm.

KEY TERMS

agonist, allele, amygdala, antagonist, anterior cingulate, attachment theory, autonomic nervous system (ANS), behavior genetics, brain stem, brief therapy, cerebellum, cognition, cognitive behavior therapy (CBT), cognitive behavioral paradigm, cognitive restructuring, corpus callosum, cortisol, diathesis, diathesis-stress, dopamine, emotion, exposure, frontal lobe, gamma-aminobutyric acid (GABA), gene, gene expression, gene-environment interaction, genetic paradigm, genotype, gray matter, heritability, hippocampus, HPA axis, hypothalamus, in vivo, Interpersonal therapy (IPT), molecular genetics, nerve impulse, neuron, neuroscience paradigm, neurotransmitters, nonshared environment, norepinephrine, object-relations theory, occipital lobe, paradigm, parasympathetic nervous system, parietal lobe, phenotype, polygenic, polymorphism, prefrontal cortex, pruning, psychodynamic paradigm, rational-emotive behavior therapy (REBT), reciprocal gene-environment interaction, reuptake, schema, second messengers, septal area, serotonin, serotonin transporter gene, shared environment, sympathetic nervous system, synapse, temporal lobe, thalamus, time-out, token economy, ventricles, white matter 5

LECTURE LAUNCHERS

1. The Manufacture of a Human Chromosome

For years, scientists have been able to create artificial chromosomes for very simple living organisms, such as yeast. A mouse chromosome was created in the lab in 1996. But in 1997, the first artificial human chromosome was created at a lab at Case Western Reserve University in Cleveland (reported in Nature Genetics, April, 1997).

What are the implications of this new technological leap? While researchers involved in the federal Human Genome Program have mapped the location of specific genes on specific chromosomes, creating artificial ones will enable scientists to study the functioning of genes within their normal context. The next big step would be packaging therapeutic genes in an artificial chromosome to introduce them to a cell. The new gene could either generate a medicinal protein or replace a defective gene. The first step in treatment would be using artificial chromosomes to treat blood diseases and diseases that affect the human immune system. Eventually, a wide range of inherited or infectious diseases might be amenable to such gene therapy.

Research in this area has grown considerably. Several websites of interest are:

1. The Institute for Genomic Research - h tt p :// www . ti g r .o r g / 2. Genome Web - h tt p :// www . g e no m e w e b. c o m / 3. The Genome Database - h tt p :// www . g db.o r g / 4. National Center for Biotechnology Information - h tt p :// www .n c b i .n l m .n i h. g o v / 6

2. Does Everything Come Down to Serotonin?

As readers work their way through the textbook, they will notice that serotonin features prominently in etiological theories for many mental disorders. Low levels of serotonin have been associated with everything from eating disorders, depression, and alcoholism to suicide and aggression.

On the other hand, animal studies have demonstrated repeatedly that environment plays a tremendously important role in serotonin levels. For example, Suomi and colleagues at the National Institute of Child, Health, and Human Development have found that childhood environments affect monkeys' behavior and serotonin systems. Monkeys with low serotonin levels are markedly aggressive and impulsive, take physical risks, and, when provided access to alcohol, drink excessively. In the wild, such monkeys are rejected by their peers, fail at mating, and often die at a young age. Lest we assume that biological factors fully account for the monkeys' behavior, however, consider the impact of environmental factors on serotonin levels. Monkeys raised without their mothers (with only peers for support) had low serotonin levels as early as 14 days of age and continuing into adulthood. Future research by this lab will include exploring whether ideal rearing environments can ameliorate the negative effects of low serotonin levels. 3. Does the Neuroscience Paradigm Make Other Paradigms Obsolete?

The 1990s were proclaimed the “decade of the brain.” Much of the research conducted has helped to highlight the impact of neuroscience on our understanding of mental illness. With this in mind, students might expect that the discovery of biochemical causes for various mental disorders invalidates the psychological paradigms. If symptoms can be explained by neurochemical changes or a “chemical imbalance,” is there still a role for paradigms that emphasize talking, thinking, and behaving in the etiology and treatment of these same disorders?

In the discussion of obsessive-compulsive disorder in Chapter 6, the text mentions a recent study (Baxter et al., 1992) that found both a medication (fluoxetine or Prozac) and a form of behavior therapy (response prevention) resulted in the same changes in brain function on PET scan in patients who improved following treatment. These findings illustrate an interconnection between the biological and behavioral paradigms, as a psychological treatment can be shown to have a direct impact on a biological process.

Another discussion of obsessive-compulsive disorder (OCD) highlights the role of psychodynamic therapy in a disorder believed to be mainly biologically caused. In “Psychodynamic psychiatry in the ‘Decade of the Brain,’” Gabbard (1992, American Journal of Psychiatry, 149, 991-998) emphasizes the way in which mind and brain interact in mental disorders. While noting the strong biological components of OCD and the lack of empirical evidence favoring psychodynamic therapy in the treatment of the disorder, Gabbard illustrates ways in which psychodynamic principles can nonetheless be valuable. Consider the following case, described by Gabbard:

A 29-year-old man with OCD is so obsessed with avoiding contamination that he insists that his mother move in with him and care for him 24 hours a day; his father is not allowed in the house. His mother must follow a 58-step ritual in making dinner, and if one step is not followed, she must discard the meal and begin again. While the patient had been prescribed clomipramine, he stopped taking it after one dose and eventually was hospitalized by his parents. The following interchange occurred with his therapist:

When he came to the hospital, I asked him why he was seeking treatment. He responded, “I'm determined to be dependent – I mean, independent.” I commented to him that he had first said “dependent,” and I inquired, “Is there perhaps a part of you that would like to be dependent?” Mr. A responded, “You mean on my mother?” I replied that I thought he would know better than I. Mr. A reflected a moment and said, “Well, she does take pretty good care of me.”

Mr. A's slip of the tongue provided a glimpse into the unconscious motivations for his resistance to treatment. Any kind of successful treatment threatened his dependent relationship with his mother. If clomipramine were likely to help him, then he would not take it.

Mr. A reportedly improved during his stay in the hospital, discovering that the hospital setting had successfully reduced his anxiety about sexual feelings toward his mother. While this treating psychiatrist noted the importance of medication in the standard treatment of OCD, he used this case as an illustration of the role of psychodynamic principles, both in understanding the unconscious wishes accompanying the biologically driven symptoms, and in handling noncompliance with the biologically based intervention. 4. Future of Psychodynamic Psychotherapy

In a special issue of Psychotherapy (1992, 29), clinicians from various theoretical orientations were asked to describe the changes they anticipated in their paradigm. Hans Strupp, writing on “The future of psychodynamic psychotherapy” (pp. 21-27), notes that psychodynamic thinking continues to be based on the notion of unconscious conflict, while paying greater attention to incorporating issues related to interpersonal experiences and emphasizing the client's subjective experience. Strupp identified the following trends in psychodynamic therapy:

1. Increasing attention to disturbances and arrests in infancy and early childhood (in contrast to Freud's emphasis on the Oedipal period). 2. Focus on treatment of personality disorders and “difficult” patients, as opposed to the “classical” neurotic conditions that Freud viewed as the primary focus of analysis. 3. Focus on the dyadic character of the therapeutic relationship, resulting in re-definition of the concepts of transference and counter transference. 4. Recognition of the importance of the patient-therapist relationship or alliance, which is more collaborative and “human” than the detached “blank screen” of classical analysts. 5. Utilization of the advances made in neuroscience and pharmacotherapy, in combination with psychotherapy. 6. Wider acceptance of group, family, and marital therapy. 7. Renewed emphasis on briefer forms of psychotherapy, largely in response to societal pressures. 8. Attempts to devise specific treatments for specific disorders, partly due to developments in the area of managed care and the investigative model of clinical trials for testing the efficacy of new drugs. 9. Development of treatment manuals. 10. Continued search for the mechanisms of change in psychotherapy.

Strupp sees these developments as “[infusing] psychodynamic psychotherapy with renewed vitality and vigor” (p. 25). 5. Carl Rogers (1902-1987)

Carl Rogers died suddenly in 1987 at the age of 85, following surgery for a broken hip. Obituaries from the Los Angeles Times (February 6, 1987) and the American Psychologist (1988, 43, 127-128) offer a glimpse into the life of this influential champion of the humanistic paradigm. Rogers was born Jan. 8, 1902, in Oak Park, Illinois. He received his doctorate from Columbia University Teachers College in 1931. Rogers founded the Center for the Study of the Person in La Jolla, California in the 1960's, where he remained active until his death. Those who knew Rogers describe him as a quiet but intent listener who was able to convey his real interest in and empathy for the phenomenological world of the individual. While caring deeply about individual persons, he doubted authority, institutions, credentials, and diagnosis. Accused in the 1940s of “destroying the unity of psychoanalysis,” Rogers successfully pioneered the new method of nondirective, client-centered therapy, turning the tables on the authority of analysts.

One of Rogers' most important contributions was his concern with conducting research in psychotherapy. He was one of the first to assert that therapists should demonstrate that their methods work; he even went so far as to tape therapy sessions at a time when the analytic relationship was considered almost sacred. Friends report that on his 80th birthday, Rogers announced that he would devote the rest of his life to working toward world peace, and to that end traveled to the Soviet Union in 1986 and led workshops in Hungary, Brazil, and South Africa. DISCUSSION STIMULATORS

1. “Medical Student's Syndrome”

Just as medical students often “diagnose” themselves as having many of the diseases they read about in such detail, Abnormal Psychology students frequently see themselves in the symptoms of mental illness described in this course. A study by Hardy & Calhoun (1997, Teaching of Psychology, 24, 192-193) indicated that students who were going to major in psychology reported more worry about their psychological well-being than did students who were majoring in another field. This study showed, however, that after completing a course in abnormal psychology, the same students were less concerned about the possibility that they might have a psychological disorder.

Because of the potential to diagnose family members as well as themselves, it is important to be sensitive in lecturing about various topics. It is good practice to give the class information about a student counseling center or other psychological services early on in the course. Still, be prepared during office hours to answer questions that are more personal than academic in nature, and have referral sources available for such times. 2. Paradigms: Brain Teasers

One of Kuhn's important arguments is that scientists' investigations are directed by the assumptions from which they begin. Sometimes the assumptions facilitate the discovery of interesting phenomena; other times the assumptions stand in the way. The following demonstrations and “brain teasers” help to illustrate the influence of one's mental set. (In fact, Kuhn links most of scientific activity to puzzle solving.)

Brain Teaser #1

Using a slide projector, show several slides of any scene (a natural landscape, a cityscape, your pet dog), beginning with the slide blurry and unrecognizable. (Be sure to set the projector out of focus in advance, so the students cannot identify the picture.) Ask a volunteer from the class to describe what he/she sees on the screen, and write the comments on the board. Have an assistant or another student gradually bring the slide into focus as the volunteer continues to describe the picture and you continue to write the description on the board. Several points can be brought out through this demonstration:

The blurry picture can be likened to the state of science in the early days as we groped for understanding, and the later recognition of the picture to the experience of scientists discovering a new phenomenon more clearly. This experience can be compared to Kuhn's view about how “normal science” progresses, rather than developing in a continuous, smooth manner, our recognition of scientific phenomena often occurs by fits and starts. Similarly, students will find themselves fumbling to understand the picture during the “pre-recognition” phase, followed by what is usually an “aha!” experience of recognition.

In order to grasp the “true” meaning of the picture, we must start out with numerous hypotheses but remain flexible about changing our perspective as new data becomes available. Students who take a longer time to recognize the subject of the picture may be wedded to cognitive “sets” established early in the exercise and not abandoned.

Brain Teaser #2

To what does the following enigma, written by Lord Byron, refer?

I'm not in earth, nor the sun, nor the moon. You may search all the sky - I'm not there. In the morning and evening - though not at noon, You may plainly perceive me, for like a balloon I am suspended in air.

Though disease may possess me, and sickness and pain, I am never in sorrow nor gloom; Though in wit and wisdom I equally reign, I am the heart of all sin and have long lived in vain; Yet I ne'er shall be found in the tomb.

Odds are it will take the class a long time to recognize that the answer is the letter “i”. (But ask students not to shout out answers right away; someone may have heard this before or be bright enough to figure it out, and puzzling over the brain teaser increases the impact of the point being made.) Once given the answer (and a new “set”), the following puzzle should be easily solved:

The beginning of eternity the end of time and space,

The beginning of every end, the end of every place.

The answer is “e”, of course.

Brain Teaser #3

“A boy is riding down the highway with his father and gets into a terrible accident. His father is killed immediately and the boy is in critical condition. He is rushed to the hospital in an ambulance, where the emergency room doctor exclaims, 'That's my son!' How can this be?”

About half the class will get the answer fairly quickly, so warn people to keep their solutions to themselves. The solution to this puzzle not only illustrates the concept of set once again, but also can lead to a discussion of sex roles if you choose. The answer, naturally, is that the doctor is the boy's mother.

Brain Teaser #4

Hold a box of tacks and a candle in front of the class. Ask how these materials can be used to fasten the candle to a wall. Students are likely to provide many ingenious answers, but most are unlikely to be able to break their “paradigmatic set.” The key is to think of using the box as a candle holder. The box can be fastened to the wall, and the candle can be set in the box.

These brainteaser demonstrations can serve as a lead-in to a discussion of paradigms and their role in science. What is a paradigm? It is a set of beliefs or a model that explains something about the world. Most importantly, it is universally accepted as being the best way to look at and understand a specific problem. There are many characteristics of mature, paradigmatic science. Among them is that there are no competing schools, each with a claim to the “only true paradigm.” Another characteristic is that knowledge is accumulated and studied for its present worth, while the historical predecessors and false starts that led to the knowledge are generally ignored. By-products of these two characteristics of a mature science are the progressive obscurity of specific knowledge to the layman and the increasing proliferation of scholarly reports and papers at the expense of longer books that try to cover a topic from every angle. A useful question for students to think about (or write about on an exam) is whether or not psychology is a pre-paradigmatic or a paradigmatic science. The discussion of abnormal psychology in the text would tend to indicate that the former is the case. The clash of paradigms is very evident both in the conception and in the treatment of mental disorders. 3. Paradigm Shift?

A current debate in clinical psychology involves treatments referred to as the “power therapies.” The common element among these treatments is the claim that they work very quickly for a variety of problems. Several of these therapies and some of their claims are listed below. Proponents of these new therapies say that mainstream psychology is stuck in an old paradigm. Students might discuss how to evaluate these therapies and whether they represent a radical change in psychology or something less.

EMDR: Eye Movement Desensitization and Reprocessing – proponents claim that by helping the patient simulate rapid eye movements while discussing blocked emotional information, they are able to better process the information, alleviating emotional distress and reducing negative responses to emotionally traumatic experiences.

TFT: Thought Field Therapy – this treatment was formulated to treat psychological distress by helping the patient balance the body's energy system. This is achieved through sequential tapping on specific acupuncture points. According to proponents of TFT, by tapping on these points according to certain “algorithms,” patients experience a reduction in panic, phobias, addictive urges, anger and other negative emotions.

EFT: Emotional Freedom Techniques – this therapy relies on tapping “energy meridians” to treat negative emotions, trauma and pain. Proponents of this therapy say it can be used for a variety of problems.

BSFF: Be Set Free Fast – is another therapy that uses an algorithm focused on acupuncture points to help relieve unresolved negative emotions and beliefs that are the cause of problems.

TAT: Tapas Acupressure Technique – proponents of this technique claim that it reduces distress due to trauma as well as allergies. It also relies on acupressure points to relieve distress. 4. Personal Consequences of Paradigms

The view of behavior that a student adopts has an effect not just on the student's view of psychology, but also on the student's view of him or herself. Do I want to think of my own behavior as being caused by unconscious processes, by my biological makeup, by past learning experiences, or by the way I construe the world? How can I change myself, if I can change myself at all? Can I learn new ways of behaving, must I have my biological make-up altered if I want to change, will change only occur after many years of analysis, or do I really need some understanding and caring? While scientists (and students) are striving to be objective, personal values can affect the answers we seek and those we accept; at times our values may persuade us more than the data we find. 5. The Rise and Fall of Behaviorism?

The APA Monitor is a monthly publication of The American Psychological Association. The December 1999 issue celebrates the first 100 years of psychology by looking back at significant events of the past century. An article entitled “Behaviorism: the rise and fall of a discipline” (p. 19) makes the claim that behaviorism has lost favor in the scientific community, partially because “behavior theories were overly simplistic and inadequate, particularly as they applied to human beings.” The article concludes with the statement that while behavior modification has been “fruitful” it has lost growth in the clinical area to cognitive therapies.

It is unclear that behaviorism has “fallen” as the article asserts. Students might be stimulated to gather evidence over the course of the term to determine what is the dominant paradigm. For example, the class might be divided into teams based on the paradigms described in the text. As the course progresses, each team gathers evidence in support of their paradigm as a “better” explanation for abnormal behavior. They could supplement the text with articles from professional journals and the popular media. At the end of the term, you might consider oral presentations, a poster session, or even a debate amongst the teams as they present the data to support their paradigm. 6. Exercise in Types of Therapeutic Communication

To help students get a flavor for the actual interchange of therapy, it is helpful to give them a chance to talk with each other in purposeful ways and observe the different effects. One method is to conduct the following exercise using different “response modes” which are commonly used in therapy.

For the first exercise, have students sit in a circle (or several smaller circles).

1. Closed-ended questions. Have students go around the circle, asking the person next to them a closed-ended question (can be yes-no, specific, or multiple- choice). That person replies, and then asks the next person a closed question. Continue this for a few minutes, or until everyone has had a turn.

2. Open-ended questions. Go around the circle again, but this time, only open-ended questions may be asked. (Spend some time explaining what an open-ended question is and give a few examples yourself.)

Discuss students' experiences with this exercise, including the following questions:

1. What differences did you observe in the types of responses generated to the two types of questions? (Closed-ended questions usually yield briefer answers and a narrower range of responses; open-ended questions allow for a broader range of responses, longer answers, and usually have a longer latency, as the responder needs more time to think.) 2. From the point of view of the responder, how did it feel to be asked the two types of questions? (Most people find answering closed-ended questions more frustrating, as they are constricted in how they are allowed to answer.) 3. From the point of view of the questioner, how did it feel to ask the two types of questions? (Most people find open-ended questions more difficult to think of.) 4. In the context of therapy, which type of question would be used for what purpose? (Closed-ended questions might be useful in assessment, where a large amount of information needs to be collected; open-ended are usually preferable for building rapport, encouraging the client to give his or her own perspective, etc.) Silence

1. “Silence is poison.” For this exercise, the group has to keep talking for 5 minutes and avoid any silence at all costs. They should be encouraged to interrupt and talk over each other. Afterward, briefly discuss their reactions. 2. “Silence is golden.” Now, have another 5-minute discussion, but this time there must be at least 5 seconds silence between speakers (advise them not to count out the seconds, though).

In discussing their reactions to this exercise, again consider what happens in the group and how the individuals feel about the different types of talking. “Poison” leads to talking faster, listening less, thinking less, and quieter students usually feel frustrated. “Golden” allows the talker more time and thought, and also provokes more anxiety. You might spend some time talking about how silence is used in psychotherapy. Reflection

While empathic reflection is one of the hallmarks of Rogerian therapy, all therapists use reflections to some extent in order to build rapport and help the client to feel understood. For this exercise, first review what a reflection is and demonstrate some reflective statements. Then have students pair up. One person talks about a topic of their choice and the other person responds using only reflections (no questions!). After five minutes, the partners switch roles. Alternatively, you might have the students remain in a group; you make statements that a client might make, and ask the students to take turns reflecting.

Students might be encouraged to try using reflections when talking to friends outside of class; first warn them to pick a time when they are prepared to listen, since this way of responding encourages people to continue talking! You could then discuss their experiences in a later class.

Interpretation

When giving an interpretation, the therapist speaks from another frame of reference, pulls in related pieces of information, and makes connections for the client. You might pass out a case description (or use a case in the text) and have the class come up with interpretations of the behavior or personality described.

Advisement

Advice giving is a controversial aspect of therapy, and interesting to discuss with students. In some forms of therapy, such as behavioral, “advice” might be common in the form of specific suggestions for behavior change. In other forms of therapy, such as client-centered, advice would never be given. You might try an exercise similar to that used for reflections, but this time only advice can be given. Discuss with students what it feels like to be on the receiving end of advice, when advisement might be appropriate, etc. 7. Diathesis-stress model? The book talks about the diathesis-stress model, which assumes that people are predisposed to react adversely to environmental stressors. The diathesis may be genetic, neurobiological, or psychological and may be caused by early-childhood experiences, genetically influenced personality traits, or sociocultural influences, among other things.

Imagine for a second, a college student named Mary. Mary is a second semester college freshman at a highly competitive Ivy League school. She is a pre-med student who spends a great deal of time studying and worrying about her future. She recently did poorly on a series of important exams. Following these perceived failures, she began to display signs of depression including, depressed mood, lack of interest in previously enjoyed activities, increased sleep, weight gain, and thoughts about death. She visits the college counseling center and is diagnosed with Major Depressive Disorder.

There are many things that may have contributed to Mary’s depression. Let’s think about these things for a moment. . Did Mary seek out the stressful situations that triggered her onset of depression? . What genetic or neurobiological aspects might have been at play? . What type of early-childhood experiences might predispose a person to depression? . What personality traits might put a person at risk for developing depression? . What social and cultural influences might contribute to depression? . What do you think contributed to her depression? 8. Using Therapy Tapes in Class

The film listed below, Three Approaches to Psychotherapy, includes an interview by Rogers. The material described above, on different modes of therapeutic communication, can be applied quite fruitfully to the showing of this film in class. Before showing the film, write the five types of responses (questions, silence, reflections, interpretations, and advisement) on the board and ask each student to make headings for each type of response mode on a piece of paper. During the showing of the film, have the class keep a record of the number of times each response mode is used. For example, whenever Rogers responds with a reflection, students should make a mark under the Reflections column. You might limit this exercise to the first five minutes of the interview. Discussion of the film can then focus on observing the predominant response modes used by the therapist, theoretical reasons for his choice of response mode, and the impact of the therapist's responses on the client. Differences between therapists depicted in the tapes will become quite dramatic as their “scores” are compared. INSTRUCTIONAL FILMS (A list of film distributors can be found at the end of this manual.)

1. Advancements in Neurology and Neurosurgery (FHS, 22 min., color, #BVL6420) “This program looks at two closely related medical specialties: neurology and neurosurgery. Dr. Mitchell Brin, co-director of the Movement Disorders Center at Mt. Sinai Medical Center, explains current knowledge on the role of drug therapy in treating such diseases as Parkinson's and multiple sclerosis. Dr. Takanori Fukushima, director of the Skull Base Surgery Center at Allegheny General Hospital, explains and performs a sophisticated neurosurgical procedure. In both instances, the doctors explain how these new surgical techniques and drug therapies are making dramatic improvements in the lives of patients.”

2. Mysteries of the Mind (FHS, 58 min., color, #BVL2029) “This program explores manic-depression, obsessive-compulsive disorder, alcoholism, and other mood disorders whose victims show a lack of control over their behavior. It examines the neurochemical and genetic components of these disorders, as well as physiological, neurological, and biomedical research into the mysteries of the brain. The program shows the nature of these mood disorders and the pain they cause patients and their families.”

3. The Otto Series (IU Media Resources, 25-27 min., color, 1975, #SO1352) A series of five films that begins with an open-ended dramatization of abnormality in a middle-aged man, then offers four perspectives for understanding and treatment: behavioral, phenomenological, psychodynamic, and social.

4. Freud Under Analysis (PBS, Nova Series 14, 58 min, color, video [1/2" VHS], 1987) This film traces the development of Freud's major ideas, including therapeutic techniques of psychoanalysis, the unconscious, and the importance of childhood experience in the psychological development of the adult. The filmmakers consider whether Freud's legacy of psychoanalysis is scientific or cultural.

5. Sigmund Freud: His Office and Home, Vienna, 1938 (Filmaker's Library, 17 min., color) This film shows the birthplace of psychoanalysis with Freud's study and collection of antiquities photographed shortly before he fled the Nazis. The film would be useful in a history of psychology class or any class dealing with Freud and his ideas.

6. Carl Gustav Jung: An Introduction (FHS, 60 min., color, #BVL3034) “Using Jung's memories as a guideline, this essay-biography explores both his exterior and his interior life. The program shows where he grew up, lived, and worked, and visualizations of his dreams and fantasies (including the famous phallus dream); analyzes the importance of his discoveries and the significance of his break with Freud; and broadly introduces the revolution Jung created and the questions he posed.”

7. Dr. Carl Rogers: Part I and Part II (PSPB, 50 min. ea., #40234 and #50314) Part I: Dr. Rogers discusses motivation, perception, learning, the self, and his development of client-centered psychotherapy. The film explains his reaction to encounter groups, pointing out their strengths and weaknesses. Part II: Dr. Rogers discusses the contemporary American educational system, student unrest on college campuses, important issues facing contemporary psychology, and his most important contributions. 8. Professor Erik Erickson: Part 1 and Part 2 (PSPB, 50 min. ea., #50012 and #50013) Erikson discusses his involvement with psychoanalysis and the development of his theories.

9. Everybody Rides the Carousel (Pyramid Media, 72 min., color, 1976) Based on the writings of psychoanalyst Erik Erikson, this animated film invites the viewer along on eight rides through the different stages of life. The film reflects the inner feelings and conflicting emotions experienced during each stage of personality development.

10. Classical and Operant Conditioning (FHS, 55 min., #BVL6541) “This program explains the nature of Behaviorism, so central to the study of human behavior, and its important applications in clinical therapy, education, and child- rearing. The program clearly explains, discusses, and illustrates the complex Classical and Operant conditioning theories of Pavlov and Skinner, and features archival footage of laboratory work with dogs and present-day research using rats in Skinner boxes, as well as numerous examples of conditioning in everyday life.”

11. B.F. Skinner and Behavior Change (Research Press, 44 min., color, 1975, #1510) In this video, professionals from various disciplines join Dr. B.F. Skinner in addressing the issues and controversies generated by behavioral psychology. Fred Keller, C.B. Ferster, Sidney Bijou, Joseph Cautela and others discuss questions, concerns, and contributions of behavioral theory and intervention. The video shows on-site interventions with patients, clients, and students in a variety of settings.

12. Dr. B. F. Skinner: Part I and Part II (PSPB, 50 min. ea., #50018 and #50019)

Part I: Dr. Skinner evaluates Freudian theory and discusses his views on motivation, operant conditioning, schedules of reinforcement, punishment, and teaching machines. Part II: Dr. Skinner discusses his novel, Walden Two, illustrating the problems of creating a society based on positive rather than negative control. Skinner evaluates the American educational system and describes the application of operant conditioning to society at large.

13. Three Approaches to Psychotherapy, I, II, and III (PEF) Wonderful series of with the major theorists (Rogers, Perls, Ellis, etc.) demonstrating their theories with actual clients.

14. The Wisdom of the Dream: The World of C.G. Jung Series (PSPB, 60 min., #01174) This film follows Jung's life from his childhood, through his years as a hospital psychiatrist, to the initial influence of Freud, to their disagreement and split. Former pupils speak of Jung's impact on their lives.