Chapter 5 • Therapeutic Approaches89

THERTHERTHERTHERTHERAPEUTIC APPROACHESAPEUTIC APPROACHESAPEUTIC APPROACHESAPEUTIC APPROACHESAPEUTIC APPROACHES

Nature and Process of PsychotherapyTherapeutic Relationship

Type of TherapiesSteps in the Formulation of a Client’s Problem (Box 5.1)Psychodynamic TherapyBehaviour TherapyRelaxation Procedures (Box 5.2)Cognitive TherapyHumanistic-existential TherapyBiomedical TherapyAlternative Therapies

Rehabilitation of the Mentally IllCONTENTS

Key Terms

Summary

Review Questions

Project Ideas

Weblinks

Pedagogical Hints

After reading this chapter, you would be able to:familiarise yourself with the basic nature and process of psychotherapy,appreciate that there are different types of therapies for helping people,understand the use of psychological forms of intervention, andknow how people with mental disorders can be rehabilitated.

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NATURE AND PROCESS OF PSYCHOTHERAPY

Psychotherapy is a voluntary relationshipbetween the one seeking treatment or theclient and the one who treats or thetherapist. The purpose of the relationshipis to help the client to solve thepsychological problems being faced by heror him. The relationship is conducive forbuilding the trust of the client so thatproblems may be freely discussed.Psychotherapies aim at changing themaladaptive behaviours, decreasing thesense of personal distress, and helping theclient to adapt better to her/hisenvironment. Inadequate marital,occupational and social adjustment alsorequires that major changes be made in anindividual’s personal environment.

All psychotherapeutic approaches havethe following characteristics : (i) there issystematic application of principlesunderlying the dif ferent theories oftherapy, (ii) persons who have receivedpractical training under expert supervisioncan practice psychotherapy, and not

In the preceding chapter, you have studied about major psychological

disorders and the distress caused by them to the patient and others. In this

chapter, you will learn about the various therapeutic methods that are used

by psychotherapists to help their patients. There are various types of

psychotherapy. Some of them focus on acquiring self-understanding; other

therapies are more action-oriented. All approaches hinge on the basic issue

of helping the patient overcome her/his debilitating condition. The

effectiveness of a therapeutic approach for a patient depends on a number

of factors such as severity of the disorder, degree of distress faced by others,

and the availability of time, effort and money, among others.

All therapeutic approaches are corrective and helping in nature. All of

them involve an interpersonal relationship between the therapist and the

client or patient. Some of them are directive in nature, such as

psychodynamic, while some are non-directive such as person-centred. In

this chapter, we will briefly discuss some of the major forms of

psychotherapy.

Introduction

everybody. An untrained person mayunintentionally cause more harm than anygood, (iii) the therapeutic situation involvesa therapist and a client who seeks andreceives help for her/his emotionalproblems (this person is the focus ofattention in the therapeutic process), and(iv) the interaction of these two persons —the therapist and the client — results inthe consolidation/formation of thetherapeutic relationship. This is aconfidential, interpersonal, and dynamicrelationship. This human relationship iscentral to any sort of psychological therapyand is the vehicle for change.

All psychotherapies aim at a few or allof the following goals :

(i) Reinforcing client’s resolve forbetterment.

(ii) Lessening emotional pressure.(iii) Unfolding the potential for positive

growth.(iv) Modifying habits.(v) Changing thinking patterns.(vi) Increasing self-awareness.(vii) Improving interpersonal relations and

communication.

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Chapter 5 • Therapeutic Approaches91

(viii)Facilitating decision-making.(ix) Becoming aware of one’s choices in

life.(x) Relating to one’s social environment in

a more creative and self-awaremanner.

Therapeutic Relationship

The special relationship between the clientand the therapist is known as thetherapeutic relationship or alliance. It isneither a passing acquaintance, nor apermanent and lasting relationship. Thereare two major components of a therapeuticalliance. The first component is thecontractual nature of the relationship inwhich two willing individuals, the clientand the therapist, enter into a partnershipwhich aims at helping the client overcomeher/his problems. The second componentof therapeutic alliance is the limitedduration of the therapy. This alliance lastsuntil the client becomes able to deal withher/his problems and take control of her/his life. This relationship has severalunique properties. It is a trusting andconfiding relationship. The high level oftrust enables the client to unburdenherself/himself to the therapist and confideher/his psychological and personalproblems to the latter. The therapistencourages this by being accepting,empathic, genuine and warm to the client.The therapist conveys by her/his wordsand behaviours that s/he is not judgingthe client and will continue to show thesame positive feelings towards the clienteven if the client is rude or confides all the‘wrong’ things that s/he may have done orthought about. This is the unconditionalpositive regard which the therapist has forthe client. The therapist has empathy forthe client. Empathy is different fromsympathy and intellectual understandingof another person’s situation. In sympathy,one has compassion and pity towards the

suffering of another but is not able to feellike the other person. Intellectualunderstanding is cold in the sense that theperson is unable to feel like the otherperson and does not feel sympathy either.On the other hand, empathy is presentwhen one is able to understand the plightof another person, and feel like the otherperson. It means understanding thingsfrom the other person’s perspective, i.e.putting oneself in the other person’s shoes.Empathy enriches the therapeuticrelationship and transforms it into ahealing relationship.

The therapeutic alliance also requiresthat the therapist must keep strictconfidentiality of the experiences, events,feelings or thoughts disclosed by the client.The therapist must not exploit the trustand the confidence of the client in anyway.Finally, it is a professional relationship,and must remain so.

Activity5.1

A classmate or friend of yours or your

favourite character in a TV serial may

have recently experienced a negative

or a traumatic life event (e.g., death

of a loved one, break-up of an

important friendship or relationship)

of which you are aware. Try to put

yourself in the other person’s shoes,

try to experience how that person is

feeling, what s/he is thinking and try

to take her/his perspective of the

entire situation. This will help you to

understand better how that person is

feeling.

(Note : This exercise may be done in

class, so that teachers can help

students in overcoming any distress

experienced).

TYPE OF THERAPIES

Though all psychotherapies aim atremoving human distress and fosteringeffective behaviour, they differ greatly in

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concepts, methods, and techniques.Psychotherapies may be classified intothree broad groups, viz. thepsychodynamic, behaviour, and existential

psychotherapies. In terms of thechronological order, psychodynamictherapy emerged first followed bybehaviour therapy while the existentialtherapies which are also called the thirdforce, emerged last. The classification ofpsychotherapies is based on the followingparameters:

1. What is the cause, which has led to the

problem?

Psychodynamic therapy is of the viewthat intrapsychic conflicts, i.e. theconflicts that are present within thepsyche of the person, are the source ofpsychological problems. According tobehaviour therapies, psychologicalproblems arise due to faulty learning ofbehaviours and cognitions. Theexistential therapies postulate that thequestions about the meaning of one’slife and existence are the cause ofpsychological problems.

2. How did the cause come into existence?

In the psychodynamic therapy,unfulfilled desires of childhood andunresolved childhood fears lead tointrapsychic conflicts. The behaviourtherapy postulates that faultyconditioning patterns, faulty learning,and faulty thinking and beliefs lead tomaladaptive behaviours that, in turn,lead to psychological problems. Theexistential therapy places importanceon the present. It is the current feelingsof loneliness, alienation, sense of futilityof one’s existence, etc., which causepsychological problems.

3. What is the chief method of treatment?

Psychodynamic therapy uses themethods of free association andreporting of dreams to elicit the

thoughts and feelings of the client. Thismaterial is interpreted to the client tohelp her/him to confront and resolvethe conflicts and thus overcomeproblems. Behaviour therapy identifiesthe faulty conditioning patterns andsets up alternate behaviouralcontingencies to improve behaviour.The cognitive methods employed in thistype of therapy challenge the faultythinking patterns of the client to helpher/him overcome psychologicaldistress. The existential therapyprovides a therapeutic environmentwhich is positive, accepting, and non-judgmental. The client is able to talkabout the problems and the therapistacts as a facilitator. The client arrivesat the solutions through a process ofpersonal growth.

4. What is the nature of the therapeutic

relationship between the client and the

therapist?

Psychodynamic therapy assumes thatthe therapist understands the client’sintrapsychic conflicts better than theclient and hence it is the therapist whointerprets the thoughts and feelings ofthe client to her/him so that s/he gainsan understanding of the same. Thebehaviour therapy assumes that thetherapist is able to discern the faultybehaviour and thought patterns of theclient. It further assumes that thetherapist is capable of finding out thecorrect behaviour and thoughtpatterns, which would be adaptive forthe client. Both the psychodynamic andthe behaviour therapies assume thatthe therapist is capable of arriving atsolutions to the client’s problems. Incontrast to these therapies, theexistential therapies emphasise that thetherapist merely provides a warm,empathic relationship in which theclient feels secure to explore the nature

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Chapter 5 • Therapeutic Approaches93

and causes of her/his problems byherself/himself.

5. What is the chief benefit to the client?

Psychodynamic therapy valuesemotional insight as the importantbenefit that the client derives from thetreatment. Emotional insight is presentwhen the client understands her/hisconflicts intellectually; is able to acceptthe same emotionally; and is able tochange her/his emotions towards theconflicts. The client’s symptoms anddistresses reduce as a consequence ofthis emotional insight. The behaviour

therapy considers changing faultybehaviour and thought patterns toadaptive ones as the chief benefit of thetreatment. Instituting adaptive or

healthy behaviour and thoughtpatterns ensures reduction of distressand removal of symptoms. Thehumanistic therapy values personal

growth as the chief benefit. Personalgrowth is the process of gainingincreasing understanding of oneself,

and one’s aspirations, emotions andmotives.

6. What is the duration of treatment?

The duration of classical psycho-analysis may continue for several years.However, several recent versions ofpsychodynamic therapies are completedin 10–15 sessions. Behaviour andcognitive behaviour therapies as well asexistential therapies are shorter and arecompleted in a few months.

Thus, dif ferent types of psycho-therapies differ on multiple parameters.However, they all share the commonmethod of providing treatment forpsychological distress through psycho-logical means. The therapist, thetherapeutic relationship, and the processof therapy become the agents of change inthe client leading to the alleviation ofpsychological distress. The process ofpsychotherapy begins by formulating theclient’s problem. Steps involved in theformulation of a client’s problem are givenin Box 5.1.

Box5.1

Steps in the Formulation of a Client’s Problem

Clinical formulation refers to formulating the problem of the client in the therapeutic modelbeing used for the treatment. The clinical formulation has the following advantages:

1. Understanding of the problem : The therapist is able to understand the full implicationsof the distress being experienced by the client.

2. Identification of the areas to be targetted for treatment in psychotherapy : The theoreticalformulation clearly identifies the problem areas to be targetted for therapy. Thus, if aclient seeks help for inability to hold a job and reports inability to face superiors, theclinical formulation in behaviour therapy would state it as lack of assertiveness skillsand anxiety. The target areas have thus been identified as inability to assert oneselfand heightened anxiety.

3. Choice of techniques for treatment : The choice of techniques for treatment depends onthe therapeutic system in which the therapist has been trained. However, even withinthis broad domain, the choice of techniques, timing of the techniques, and expectationsof outcome of the therapy depend upon the clinical formulation.

The clinical formulation is an ongoing process. Formulations may require reformulationsas clinical insights are gained in the process of therapy. Usually the first one or two sessionsyield enough clinical material for the initial clinical formulation. It is not advisable to startpsychotherapy without a clinical formulation.

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The following sections explainrepresentative therapies from each of thethree major systems of psychotherapymentioned earlier.

Psychodynamic Therapy

As you have already read, thepsychodynamic therapy pioneered bySigmund Freud is the oldest form ofpsychotherapy. His close collaborator CarlJung modified it to what came to be knownas the analytical psychotherapy.Subsequently, Freud’s successors, knownas Neo-Freudians, established their ownversions of classical psychodynamictherapy. Broadly, the psychodynamictherapy has conceptualised the structureof the psyche, dynamics between differentcomponents of the psyche, and the sourceof psychological distress. You have alreadystudied these concepts in the chapters onSelf and Personality, and PsychologicalDisorders. The method of treatment, stepsin the treatment, nature of the therapeuticrelationship, and the expected outcomefrom the psychodynamic therapy areexplained below.

Methods of Eliciting the Nature of

Intrapsychic Conflict

Since the psychoanalytic approach viewsintrapsychic conflicts to be the cause ofpsychological disorder, the first step in thetreatment is to elicit this intrapsychicconflict. Psychoanalysis has invented freeassociation and dream interpretation astwo important methods for eliciting theintrapsychic conflicts. The free associationmethod is the main method forunderstanding the client’s problems. Once

a therapeutic relationship is established,and the client feels comfortable, thetherapist makes her/him lie down on thecouch, close her/his eyes and asks her/him to speak whatever comes to mindwithout censoring it in anyway. The clientis encouraged to freely associate onethought with another, and this method iscalled the method of free association. Thecensoring superego and the watchful egoare kept in abeyance as the client speakswhatever comes to mind in an atmospherethat is relaxed and trusting. As thetherapist does not interrupt, the free flowof ideas, desires and conflicts of theunconscious, which had been suppressedby the ego, emerge into the consciousmind. This free uncensored verbalnarrative of the client is a window into theclient’s unconscious to which the therapistgains access. Along with this technique,the client is asked to write down her/hisdreams upon waking up. Psychoanalystslook upon dreams as symbols of theunfulfilled desires present in theunconscious. The images of the dreams aresymbols which signify intrapsychic forces.Dreams use symbols because they areindirect expressions and hence would notalert the ego. If the unfulfilled desires areexpressed directly, the ever-vigilant egowould suppress them and that would leadto anxiety. These symbols are interpretedaccording to an accepted convention oftranslation as the indicators of unfulfilleddesires and conflicts.

Modality of Treatment

Transference and Interpretation are themeans of treating the patient. As theunconscious forces are brought into theconscious realm through free associationand dream interpretation described above,the client starts identifying the therapistwith the authority figures of the past,usually childhood. The therapist may be

Gather information about some

institutions you know which offer

psychiatric/psychotherapeutic help.

Activity5.2

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Chapter 5 • Therapeutic Approaches95

seen as the punitive father, or as thenegligent mother. The therapist maintainsa non-judgmental yet permissive attitudeand allows the client to continue with thisprocess of emotional identification. This isthe process of transference. The therapistencourages this process because ithelps her/him in understanding theunconscious conflicts of the client. Theclient acts out her/his frustrations, anger,fear, and depression that s/he harbouredtowards that person in the past, but couldnot express at that time. The therapistbecomes a substitute for that person inthe present. This stage is calledtransference neurosis. A full-blowntransference neurosis is helpful in makingthe therapist aware of the nature ofintrapsychic conflicts suffered by theclient. There is the positive transferencein which the client idolises, or falls inlove with the therapist, and seeksthe therapist’s approval. Negativetransference is present when the clienthas feelings of hostility, anger, andresentment towards the therapist.

The process of transference is met withresistance. Since the process oftransference exposes the unconsciouswishes and conflicts, thereby increasingthe distress levels, the client resiststransference. Due to resistance, the clientopposes the progress of therapy in orderto protect herself/himself from the recallof painful unconscious memories.Resistance can be conscious orunconscious. Conscious resistance ispresent when the client deliberately hidessome information. Unconscious resistanceis assumed to be present when the clientbecomes silent during the therapy session,recalls trivial details without recalling theemotional ones, misses appointments, andcomes late for therapy sessions. Thetherapist overcomes the resistance byrepeatedly confronting the patient about itand by uncovering emotions such as

anxiety, fear, or shame, which are causingthe resistance.

Interpretation is the fundamentalmechanism by which change is effected.Confrontation and clarification are thetwo analytical techniques of interpretation.In confrontation, the therapist points outto the client an aspect of her/his psychethat must be faced by the client.Clarification is the process by which thetherapist brings a vague or confusing eventinto sharp focus. This is done byseparating and highlighting importantdetails about the event from unimportantones. Interpretation is a more subtleprocess. It is considered to be the pinnacleof psychoanalysis. The therapist uses theunconscious material that has beenuncovered in the process of freeassociation, dream interpretation,transference and resistance to make theclient aware of the psychic contents andconflicts which have led to the occurrenceof certain events, symptoms and conflicts.Interpretation can focus on intrapsychicconflicts or on deprivations suffered inchildhood. The repeated process of usingconfrontation, clarification, and inter-pretation is known as working through.

Working through helps the patient tounderstand herself/himself and the sourceof the problem and to integrate theuncovered material into her/his ego.

The outcome of working through isinsight. Insight is not a sudden event buta gradual process wherein the unconsciousmemories are repeatedly integrated intoconscious awareness; these unconsciousevents and memories are re-experienced intransference and are worked through. Asthis process continues, the client starts tounderstand herself/himself better at anintellectual and emotional level, and gainsinsight into her/his conflicts andproblems. The intellectual understandingis the intellectual insight. The emotionalunderstanding, acceptance of one’s

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irrational reaction to the unpleasant eventsof the past, and the willingness to changeemotionally as well as making the changeis emotional insight. Insight is the endpoint of therapy as the client has gaineda new understanding of herself/himself. Inturn, the conflicts of the past, defencemechanisms and physical symptoms areno longer present and the client becomesa psychologically healthy person.Psychoanalysis is terminated at thisstage.

Duration of Treatment

Psychoanalysis lasts for several years, withone hour session for 4–5 days per week.It is an intense treatment. There are threestages in the treatment. Stage one is theinitial phase. The client becomes familiarwith the routines, establishes a therapeuticrelationship with the analyst, and getssome relief with the process of recollectingthe superficial materials from theconsciousness about the past and presenttroublesome events. Stage two is themiddle phase, which is a long process. Itis characterised by transference, resistanceon the part of the client, and confrontationand clarification, i.e. working through onthe therapist’s part. All these processesfinally lead to insight. The third phase isthe termination phase wherein therelationship with the analyst is dissolvedand the client prepares to leave thetherapy.

Behaviour Therapy

Behaviour therapies postulate thatpsychological distress arises because offaulty behaviour patterns or thoughtpatterns. It is, therefore, focused on thebehaviour and thoughts of the client in thepresent. The past is relevant only to theextent of understanding the origins of thefaulty behaviour and thought patterns. Thepast is not activated or relived. Only the

faulty patterns are corrected in thepresent.

The clinical application of learningtheory principles constitute behaviourtherapy. Behaviour therapy consists of alarge set of specific techniques andinterventions. It is not a unified theory,which is applied irrespective of the clinicaldiagnosis or the symptoms present. Thesymptoms of the client and the clinicaldiagnosis are the guiding factors in theselection of the specific techniques orinterventions to be applied. Treatment ofphobias or excessive and crippling fearswould require the use of one set oftechniques while that of anger outburstswould require another. A depressed clientwould be treated differently from a clientwho is anxious. The foundation ofbehaviour therapy is on formulatingdysfunctional or faulty behaviours, thefactors which reinforce and maintain thesebehaviours, and devising methods bywhich they can be changed.

Method of Treatment

The client with psychological distress orwith physical symptoms, which cannot beattributed to physical disease, isinterviewed with a view to analyse her/hisbehaviour patterns. Behavioural analysis isconducted to find malfunctioningbehaviours, the antecedents of faultylearning, and the factors that maintainor continue faulty learning. Malfunctioning

behaviours are those behaviours whichcause distress to the client. Antecedent

factors are those causes which predisposethe person to indulge in that behaviour.Maintaining factors are those factors whichlead to the persistence of the faultybehaviour. An example would be a youngperson who has acquired themalfunctioning behaviour of smoking andseeks help to get rid of smoking.Behavioural analysis conducted by

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interviewing the client and the familymembers reveals that the person startedsmoking when he was preparing for theannual examination. He had reported relieffrom anxiety upon smoking. Thus, anxiety-provoking situation becomes the causativeor antecedent factor. The feeling of reliefbecomes the maintaining factor for him tocontinue smoking. The client has acquiredthe operant response of smoking, which ismaintained by the reinforcing value of relieffrom anxiety.

Once the faulty behaviours whichcause distress, have been identified, atreatment package is chosen. The aim ofthe treatment is to extinguish or eliminatethe faulty behaviours and substitute themwith adaptive behaviour patterns. Thetherapist does this through establishingantecedent operations and consequentoperations. Antecedent operations controlbehaviour by changing something thatprecedes such a behaviour. The changecan be done by increasing or decreasingthe reinforcing value of a particularconsequence. This is called establishing

operation. For example, if a child givestrouble in eating dinner, an establishingoperation would be to decrease thequantity of food served at tea time. Thiswould increase the hunger at dinner andthereby increase the reinforcing value of

food at dinner. Praising the child whens/he eats properly tends to encourage thisbehaviour. The antecedent operation is thereduction of food at tea time and the

consequent operation is praising the childfor eating dinner. It establishes theresponse of eating dinner.

Behavioural Techniques

A range of techniques is available forchanging behaviour. The principles of thesetechniques are to reduce the arousal levelof the client, alter behaviour through

classical conditioning or operantconditioning with different contingencies ofreinforcements, as well as to use vicariouslearning procedures, if necessary.

Negative reinforcement and aversiveconditioning are the two major techniquesof behaviour modification. As you havealready studied in Class XI, responses that

lead organisms to get rid of painful stimulior avoid and escape from them providenegative reinforcement. For example, onelearns to put on woollen clothes, burnfirewood or use electric heaters to avoid the

unpleasant cold weather. One learns tomove away from dangerous stimuli becausethey provide negative reinforcement.Aversive conditioning refers to repeated

association of undesired response with anaversive consequence. For example, an

Box5.2

Relaxation Procedures

Anxiety is a manifestation of the psychological distress for which the client seeks treatment.The behavioural therapist views anxiety as increasing the arousal level of the client, therebyacting as an antecedent factor in causing the faulty behaviour. The client may smoke todecrease anxiety, may indulge in other activities such as eating, or be unable to concentratefor long hours on her/his study because of the anxiety. Therefore, reduction of anxiety woulddecrease the unwanted behaviours of excessive eating or smoking. Relaxation procedures areused to decrease the anxiety levels. For instance, progressive muscular relaxation and meditation

induce a state of relaxation. In progressive muscular relaxation, the client is taught to contractindividual muscle groups in order to give the awareness of tenseness or muscular tension.After the client has learnt to tense the muscle group such as the forearm, the client is askedto let go the tension. The client is told that the tension is what the client has at present andthat s/he has to get into the opposite state. With repeated practice the client learns to relax allthe muscles of the body. You will learn about meditation at a later point in this chapter.

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alcoholic is given a mild electric shock andasked to smell the alcohol. With repeatedpairings the smell of alcohol is aversive asthe pain of the shock is associated with itand the person will give up alcohol. If anadaptive behaviour occurs rarely, positivereinforcement is given to increase thedeficit. For example, if a child does not dohomework regularly, positive reinforcementmay be used by the child’s mother bypreparing the child’s favourite dishwhenever s/he does homework at theappointed time. The positive reinforcementof food will increase the behaviour of doinghomework at the appointed time. Personswith behavioural problems can be given atoken as a reward every time a wantedbehaviour occurs. The tokens are collectedand exchanged for a reward such as anouting for the patient or a treat for the child.This is known as token economy.

Unwanted behaviour can be reducedand wanted behaviour can be increasedsimultaneously through differential

reinforcement. Positive reinforcement forthe wanted behaviour and negativereinforcement for the unwanted behaviourattempted together may be one suchmethod. The other method is to positivelyreinforce the wanted behaviour and ignorethe unwanted behaviour. The latter methodis less painful and equally effective. Forexample, let us consider the case of a girlwho sulks and cries when she is not takento the cinema when she asks. The parentis instructed to take her to the cinema ifshe does not cry and sulk but not to takeher if she does. Further, the parent isinstructed to ignore the girl when she criesand sulks. The wanted behaviour ofpolitely asking to be taken to the cinemaincreases and the unwanted behaviour ofcrying and sulking decreases.

You read about phobias or irrationalfears in the previous chapter. Systematicdesensitisation is a technique introducedby Wolpe for treating phobias or irrational

fears. The client is interviewed to elicit fear-provoking situations and together with theclient, the therapist prepares a hierarchyof anxiety-provoking stimuli with the leastanxiety-provoking stimuli at the bottom ofthe hierarchy. The therapist relaxes theclient and asks the client to think aboutthe least anxiety-provoking situation.Box 5.2 gives details of relaxationprocedures. The client is asked to stopthinking of the fearful situation if theslightest tension is felt. Over sessions, theclient is able to imagine more severe fear-provoking situations while maintaining therelaxation. The client gets systematicallydesensitised to the fear.

The principle of reciprocal inhibitionoperates here. This principle states that thepresence of two mutually opposing forcesat the same time, inhibits the weaker force.Thus, the relaxation response is first builtup and mildly anxiety-provoking scene isimagined, and the anxiety is overcome bythe relaxation. The client is able to tolerateprogressively greater levels of anxietybecause of her/his relaxed state.Modelling is the procedure wherein theclient learns to behave in a certain way byobserving the behaviour of a role model orthe therapist who initially acts as the rolemodel. Vicarious learning, i.e. learning byobserving others, is used and through a

Activity5.3

Your friend is feeling very nervous

and panicky before the examinations.

S/he is pacing up and down, is

unable to study and feels s/he has

forgotten all that s/he has learnt. Try

to help her/him to relax by inhaling

(taking in a deep breath), holding it

for sometime (5–10 seconds), then

exhaling (releasing the breath). Ask

her/him to repeat this 5–10 times.

Also ask her/him to remain focused

on her/his breathing. You can do

the same exercise when you feel

nervous.

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process of rewarding small changes in thebehaviour, the client gradually learns toacquire the behaviour of the model.

There is a great variety of techniques inbehaviour therapy. The skill of thetherapist lies in conducting an accuratebehavioural analysis and building atreatment package with the appropriatetechniques.

Cognitive Therapy

Cognitive therapies locate the cause ofpsychological distress in irrationalthoughts and beliefs. Albert Ellisformulated the Rational Emotive Therapy(RET). The central thesis of this therapy isthat irrational beliefs mediate between theantecedent events and their consequences.The first step in RET is the antecedent-

belief-consequence (ABC) analysis.Antecedent events, which caused thepsychological distress, are noted. Theclient is also interviewed to find theirrational beliefs, which are distorting thepresent reality. Irrational beliefs may notbe supported by empirical evidence in theenvironment. These beliefs arecharacterised by thoughts with ‘musts’and ‘shoulds’, i.e. things ‘must’ and‘should’ be in a particular manner.Examples of irrational beliefs are, “Oneshould be loved by everybody all the time”,“Human misery is caused by externalevents over which one does not have anycontrol”, etc. This distorted perception ofthe antecedent event due to the irrationalbelief leads to the consequence, i.e.negative emotions and behaviours.Irrational beliefs are assessed throughquestionnaires and interviews. In theprocess of RET, the irrational beliefs arerefuted by the therapist through a processof non-directive questioning. The nature ofquestioning is gentle, without probing orbeing directive. The questions make theclient to think deeper into her/his

assumptions about life and problems.Gradually the client is able to change theirrational beliefs by making a change inher/his philosophy about life. The rationalbelief system replaces the irrational beliefsystem and there is a reduction inpsychological distress.

Another cognitive therapy is that ofAaron Beck. His theory of psychologicaldistress characterised by anxiety ordepression, states that childhoodexperiences provided by the family andsociety develop core schemas or systems,which include beliefs and action patternsin the individual. Thus, a client, who wasneglected by the parents as a child,develops the core schema of “I am notwanted”. During the course of life, a criticalincident occurs in her/his life. S/he ispublicly ridiculed by the teacher in school.This critical incident triggers the coreschema of “I am not wanted” leading to thedevelopment of negative automaticthoughts. Negative thoughts are persistentirrational thoughts such as “nobody lovesme”, “I am ugly”, “I am stupid”, “I will notsucceed”, etc. Such negative automaticthoughts are characterised by cognitivedistortions. Cognitive distortions are waysof thinking which are general in nature butwhich distort the reality in a negativemanner. These patterns of thoughtare called dysfunctional cognitivestructures. They lead to errors of cognitionabout the social reality.

Repeated occurrence of these thoughtsleads to the development of feelings ofanxiety and depression. The therapist usesquestioning, which is gentle, non-threatening disputation of the client’sbeliefs and thoughts. Examples of suchquestion would be, “Why should everyonelove you?”, “What does it mean to you tosucceed?”, etc. The questions make theclient think in a direction opposite to thatof the negative automatic thoughtswhereby s/he gains insight into the nature

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of her/his dysfunctional schemas, and isable to alter her/his cognitive structures.The aim of the therapy is to achieve thiscognitive restructuring which, in turn,

reduces anxiety and depression.Similar to behaviour therapy, cognitive

therapy focuses on solving a specificproblem of the client. Unlike psycho-

dynamic therapy, behaviour therapy isopen, i.e. the therapist shares her/hismethod with the client. It is short, lastingbetween 10–20 sessions.

Cognitive Behaviour Therapy

The most popular therapy presently is theCognitive Behaviour Therapy (CBT).Research into the outcome and

effectiveness of psychotherapy hasconclusively established CBT to be a shortand efficacious treatment for a wide rangeof psychological disorders such as anxiety,

depression, panic attacks, and borderlinepersonality, etc. CBT adopts a bio-psychosocial approach to the delineation ofpsychopathology. It combines cognitivetherapy with behavioural techniques.

The rationale is that the client’s distresshas its origins in the biological,psychological, and social realms. Hence,addressing the biological aspects through

relaxation procedures, the psychologicalones through behaviour therapy andcognitive therapy techniques and the socialones with environmental manipulations

makes CBT a comprehensive techniquewhich is easy to use, applicable to a varietyof disorders, and has proven efficacy.

Humanistic-existential Therapy

The humanistic-existential therapiespostulate that psychological distress arisesfrom feelings of loneliness, alienation, andan inability to find meaning and genuine

fulfilment in life. Human beings aremotivated by the desire for personal growth

and self-actualisation, and an innate needto grow emotionally. When these needs arecurbed by society and family, humanbeings experience psychological distress.Self-actualisation is defined as an innateor inborn force that moves the person tobecome more complex, balanced, andintegrated, i.e. achieving the complexityand balance without being fragmented.Integrated means a sense of whole, beinga complete person, being in essence thesame person in spite of the variety ofexperiences that one is subjected to. Justas lack of food or water causes distress,frustration of self-actualisation also causesdistress.

Healing occurs when the client is ableto perceive the obstacles to self-actualisation in her/his life and is able toremove them. Self-actualisation requiresfree emotional expression. The family andsociety curb emotional expression, as it isfeared that a free expression of emotionscan harm society by unleashingdestructive forces. This curb leads todestructive behaviour and negativeemotions by thwarting the process ofemotional integration. Therefore, thetherapy creates a permissive, non-judgmental and accepting atmosphere inwhich the client’s emotions can be freelyexpressed and the complexity, balance andintegration could be achieved. Thefundamental assumption is that the clienthas the freedom and responsibility tocontrol her/his own behaviour. Thetherapist is merely a facilitator and guide.It is the client who is responsible for thesuccess of therapy. The chief aim of thetherapy is to expand the client’s awareness.Healing takes place by a process ofunderstanding the unique personalexperience of the client by herself/himself.The client initiates the process of self-growth through which healing takesplace.

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Existential Therapy

Victor Frankl, a psychiatrist andneurologist propounded the Logotherapy.Logos is the Greek word for soul andLogotherapy means treatment for the soul.Frankl calls this process of findingmeaning even in life-threateningcircumstances as the process of meaningmaking. The basis of meaning making is aperson’s quest for finding the spiritualtruth of one’s existence. Just as there isan unconscious, which is the repository ofinstincts (see Chapter 2), there is aspiritual unconscious, which is thestorehouse of love, aesthetic awareness,and values of life. Neurotic anxieties arisewhen the problems of life are attached tothe physical, psychological or spiritualaspects of one’s existence. Franklemphasised the role of spiritual anxietiesin leading to meaninglessness and henceit may be called an existential anxiety, i.e.neurotic anxiety of spiritual origin. Thegoal of logotherapy is to help the patientsto find meaning and responsibility intheir life irrespective of their lifecircumstances. The therapist emphasisesthe unique nature of the patient’s life andencourages them to find meaning in theirlife.

In Logotherapy, the therapist is openand shares her/his feelings, values andhis/her own existence with the client. Theemphasis is on here and now. Transferenceis actively discouraged. The therapistreminds the client about the immediacy ofthe present. The goal is to facilitate theclient to find the meaning of her/his being.

Client-centred Therapy

Client-centred therapy was given by CarlRogers. Rogers combined scientific rigourwith the individualised practice of client-centred psychotherapy. Rogers broughtinto psychotherapy the concept of self, withfreedom and choice as the core of one’sbeing. The therapy provides a warm

relationship in which the client canreconnect with her/his disintegratedfeelings. The therapist shows empathy, i.e.understanding the client’s experience as ifit were her/his own, is warm and hasunconditional positive regard, i.e. totalacceptance of the client as s/he is.Empathy sets up an emotional resonancebetween the therapist and the client.Unconditional positive regard indicatesthat the positive warmth of the therapistis not dependent on what the client revealsor does in the therapy sessions. Thisunique unconditional warmth ensures thatthe client feels secure and can trust thetherapist. The client feels secure enough toexplore her/his feelings. The therapistreflects the feelings of the client in a non-judgmental manner. The reflection isachieved by rephrasing the statements ofthe client, i.e. seeking simple clarificationsto enhance the meaning of the client’sstatements. This process of reflection helpsthe client to become integrated. Personalrelationships improve with an increase inadjustment. In essence, this therapy helpsa client to become her/his real self with thetherapist working as a facilitator.

Gestalt Therapy

The German word gestalt means ‘whole’.This therapy was given by Freiderick (Fritz)Perls together with his wife Laura Perls.The goal of gestalt therapy is to increasean individual’s self-awareness and self-acceptance. The client is taught torecognise the bodily processes and theemotions that are being blocked out fromawareness. The therapist does this byencouraging the client to act out fantasiesabout feelings and conflicts. This therapycan also be used in group settings.

Biomedical Therapy

Medicines may be prescribed to treatpsychological disorders. Prescription ofmedicines for treatment of mental

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disorders is done by qualified medicalprofessionals known as psychiatrists. Theyare medical doctors who have specialisedin the understanding, diagnosis andtreatment of mental disorders. The natureof medicines used depends on the natureof the disorders. Severe mental disorderssuch as schizophrenia or bipolar disorderrequire anti-psychotic drugs. Commonmental disorders such as generalisedanxiety or reactive depression may alsorequire milder drugs. The medicinesprescribed to treat mental disorders cancause side-ef fects which need to beunderstood and monitored. Hence, it isessential that medication is given underproper medical supervision. Even thedrugs which normal individuals use to stayawake to study for examinations or to geta ‘high’ at a party have dangerousside-effects. These drugs can causeaddiction, and harm the brain and thebody. Therefore, it is dangerous to self-medicate with drugs which affect the mind.

You must have seen people with mentalproblems being given electric shocks infilms. Electro-convulsive Therapy (ECT)is another form of biomedical therapy. Mildelectric shock is given via electrodes to thebrain of the patient to induce convulsions.The shock is given by the psychiatrist onlywhen it is necessary for the improvementof the patient. ECT is not a routinetreatment and is given only when drugs arenot effective in controlling the symptomsof the patient.

Factors Contributing to Healing inPsychotherapy

As we have read, psychotherapy is atreatment of psychological distress. Thereare several factors which contribute to thehealing process. Some of these factors areas follows :1. A major factor in the healing is the

techniques adopted by the therapist

and the implementation of the samewith the patient/client. If thebehavioural system and the CBT schoolare adopted to heal an anxious client,the relaxation procedures and thecognitive restructuring largelycontribute to the healing.

2. The therapeutic alliance, which isformed between the therapist and thepatient/client, has healing properties,because of the regular availability of thetherapist, and the warmth andempathy provided by the therapist.

3. At the outset of therapy while thepatient/client is being interviewed inthe initial sessions to understand thenature of the problem, s/he unburdensthe emotional problems being faced.This process of emotional unburdeningis known as catharsis, and it hashealing properties.

4. There are several non-specific factorsassociated with psychotherapy. Someof these factors are attributed to thepatient/client and some to thetherapist. These factors are callednon-specific because they occur acrossdifferent systems of psychotherapy andacross different clients/patients anddifferent therapists. Non-specific factorsattributable to the client/patient aremotivation for change, expectation ofimprovement due to the treatment, etc.These are called patient variables.Non-specific factors attributable to thetherapist are positive nature, absenceof unresolved emotional conflicts,presence of good mental health,etc. These are called therapist

variables.

Ethics in Psychotherapy

Some of the ethical standards that need tobe practiced by professional psycho-therapists are :1. Informed consent needs to be taken.

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2. Confidentiality of the client should bemaintained.

3. Alleviating personal distress andsuffering should be the goal of allattempts of the therapist.

4. Integrity of the practitioner -clientrelationship is important.

5. Respect for human rights and dignity.6. Professional competence and skills are

essential.

Alternative Therapies

Alternative therapies are so called, becausethey are alternative treatment possibilitiesto the conventional drug treatment orpsychotherapy. There are many alternativetherapies such as yoga, meditation,acupuncture, herbal remedies and so on.In the past 25 years, yoga and meditationhave gained popularity as treatmentprogrammes for psychological distress.

Yoga is an ancient Indian techniquedetailed in the Ashtanga Yoga of Patanjali’sYoga Sutras. Yoga as it is commonly calledtoday either refers to only the asanas orbody posture component or to breathingpractices or pranayama, or to acombination of the two. Meditation refersto the practice of focusing attention onbreath or on an object or thought or amantra. Here attention is focused. InVipasana meditation, also known asmindfulness-based meditation, there is nofixed object or thought to hold theattention. The person passively observesthe various bodily sensations and thoughtsthat are passing through in her or hisawareness.

The rapid breathing techniques toinduce hyperventilation as in Sudarshana

Kriya Yoga (SKY) is found to be abeneficial, low-risk, low-cost adjunct to thetreatment of stress, anxiety, post-traumaticstress disorder (PTSD), depression, stress-related medical illnesses, substance abuse,and rehabilitation of criminal offenders.

SKY has been used as a public healthintervention technique to alleviate PTSD insurvivors of mass disasters. Yogatechniques enhance well-being, mood,attention, mental focus, and stresstolerance. Proper training by a skilledteacher and a 30-minute practice every daywill maximise the benefits. Researchconducted at the National Institute ofMental Health and Neurosciences(NIMHANS), India, has shown that SKYreduces depression. Further, alcoholicpatients who practice SKY have reduceddepression and stress levels. Insomnia istreated with yoga. Yoga reduces the timeto go to sleep and improves the quality ofsleep.

Kundalini Yoga taught in the USA hasbeen found to be effective in treatment ofmental disorders. The Institute for Non-linear Science, University of California, SanDiego, USA has found that Kundalini Yoga

is effective in the treatment of obsessive-compulsive disorder. Kundalini Yoga

combines pranayama or breathingtechniques with chanting of mantras.Prevention of repeated episodes ofdepression may be helped by mindfulness-based meditation or Vipasana. Thismeditation would help the patients toprocess emotional stimuli better and henceprevent biases in the processing of thesestimuli.

REHABILITATION OF THE MENTALLY ILL

The treatment of psychological disordershas two components, i.e. reduction ofsymptoms, and improving the level offunctioning or quality of life. In the caseof milder disorders such as generalisedanxiety, reactive depression or phobia,reduction of symptoms is associated withan improvement in the quality of life.However, in the case of severe mentaldisorders such as schizophrenia, reductionof symptoms may not be associated with

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Review Questions

1. Describe the nature and scope of psychotherapy. Highlight the importance oftherapeutic relationship in psychotherapy.

2. What are the different types of psychotherapy? On what basis are they classified?3. A therapist asks the client to reveal all her/his thoughts including early childhood

experiences. Describe the technique and type of therapy being used.4. Discuss the various techniques used in behaviour therapy.5. Explain with the help of an example how cognitive distortions take place.6. Which therapy encourages the client to seek personal growth and actualise their

potential? Write about the therapies which are based on this principle.

Key Terms

Alternative therapy, Behaviour therapy, Biomedical therapy, Client-centred therapy, Cognitive behaviourtherapy, Empathy, Gestalt therapy, Humanistic therapy, Psycho dynamic therapy, Psychotherapy,Rehabilitation, Resistance, Self-actualisation, Therapeutic alliance, Transference, Unconditional positiveregard.

• Psychotherapy is a treatment for the healing of psychological distress. It is not a

homogenous treatment method. There are about 400 different types of psychotherapy.

• Psychoanalysis, behavioural, cognitive and humanistic-existential are the important

systems of psychotherapy. There are many schools within each of the above systems.

• The important components of psychotherapy are the clinical formulation, i.e. statement

of the client’s problem and treatment in the framework of a particular therapy.

• Therapeutic alliance is the relation between the therapist and the client in which the

client has trust in the therapist and the therapist has empathy for the client.

• The predominant mode of psychotherapy for adults with psychological distress is

individual psychotherapy. The therapist requires to be professionally trained before

embarking on the journey of psychotherapy.

• Alternative therapies such as some yogic and meditative practices have been found

to be effective in treating certain psychological disorders.

• Rehabilitation of the mentally ill is necessary to improve their quality of life once their

active symptoms are reduced.

an improvement in the quality of life. Manypatients suffer from negative symptomssuch as disinterest and lack of motivationto do work or to interact with people.Rehabilitation is required to help suchpatients become self-sufficient. The aim ofrehabilitation is to empower the patient tobecome a productive member of society tothe extent possible. In rehabilitation, thepatients are given occupational therapy,

social skills training, and vocational

therapy. In occupational therapy, thepatients are taught skills such as candle

making, paper bag making and weaving tohelp them to form a work discipline. Socialskills training helps the patients to developinterpersonal skills through role play,imitation and instruction. The objective isto teach the patient to function in a socialgroup. Cognitive retraining is given toimprove the basic cognitive functions ofattention, memory and executive functions.After the patient improves sufficiently,vocational training is given wherein thepatient is helped to gain skills necessaryto undertake productive employment.

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Weblinks

http://www.sciencedirect.comhttp://allpsych.comhttp://mentalhealth.com

Pedagogical Hints

1. Students could be asked to connectthe different therapeuticapproaches to some of the theoriesof personality they have studied inChapter 2 on Self and Personality.

2. Role-play and dramatisation ofcertain student-related behaviouralissues, such as break-up ofrelationship with a friend wouldevoke interest among the studentsand also emphasise the applicationof psychology.

3. As therapy is a highly skilledprocess requiring professionaltraining, students should berefrained from treating it in afrivolous manner.

4. Any activity/discussion, which mayhave a serious impact on the psycheof the students, should be properlytransacted in the presence of theteacher.

ProjectIdeas

1. In school at times you get good points (or gold points or stars) when you do well andbad or black points when you do something wrong. This is an example of a tokensystem. With the help of your classmates make a list of all those school and classroomactivities for which you are rewarded or receive praise from your teacher or appreciationfrom your friends. Also make a list of all those activities for which your teacher scoldsyou or your classmates get angry with you.

2. Describe a person in your past or present who has consistently demonstratedunconditional positive regard towards you. What effect, if any, did (or does) this haveon you? Explain. Gather the same information from more friends and prepare a report.

7. What are the factors that contribute to healing in psychotherapy? Enumerate someof the alternative therapies.

8. What are the techniques used in the rehabilitation of the mentally ill?9. How would a social learning theorist account for a phobic fear of lizards/cockroaches?

How would a psychoanalyst account for the same phobia?10. Should Electro-convulsive Therapy (ECT) be used in the treatment of mental disorders?11. What kind of problems is cognitive behaviour therapy best suited for?

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