SHIVANI RANA

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CHAPTER 5
THERAPEUTIC APPROACHES

WHAT IS PSYCHOTHERAPY?
Psychotherapy is a voluntary relationship between the one seeking treatment or
the client and the one who treats or the therapist. This is a confidential
interpersonal and dynamic relationship. The purpose of the relationship is to
help the client to solve the psychological problems being faced by the him/her.
Psychotherapies aim at changing the maladaptive behaviours, decreasing the
sense of personal distress, and helping the client to adapt better to his/her
environment.

WHAT ARE THE CHARACTERISTICS OF

PSYCHOTHERAPY?
• There is a systematic application of principles underlying the different
theories of therapy.
• Persons who have received practical training under expert supervision can
practice psychotherapy, and not anybody.
• The therapeutic situation involves a therapist and a client who seeks and
receives help for his/her emotional problems.
• The interaction of these two persons, the therapist and the client results in
the formation of the therapeutic relationship.

GOALS OF PSYCHOTHERAPY
• Reinforcing client’s resolve for betterment.
• Lessening emotional pressure
• Unfolding the potential for positive growth.
• Modifying habits

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• Changing thinking patterns

• Increasing self awareness
• Improving interpersonal relations and communication
• Facilitating decision making
• Becoming aware of one’s choices in life
• Relating to one’s social environment in a more creative and a self aware
manner.

WHAT IS THE NATURE OF A THERAPEUTIC

RELATIONSHIP?
The special relationship between the client and the therapist is known as the
therapeutic relationship or alliance.
There are two major components of a therapeutic alliance.
• Contractual nature of the relationship in which two willing individuals, the
client and the therapist, enter into a partnership which aims at helping the
client overcome her/his problems.
• Limited duration of the therapy. This alliance lasts until the client becomes
able to deal with her/his problems and take control of her/ his life.

Properties:
• It is a trusting and confiding relationship.
• The therapist encourages this by being accepting, empathic, genuine and
warm to the client.
• The therapist conveys by her/his words and behaviours that s/he is not
judging the client and will continue to show the same positive feelings
towards the client even if the client is rude or confides all the ‘wrong’ things
that s/he may have done or thought about. This is the unconditional
positive regard which the therapist has for the client.
• The therapist has empathy for the client. Empathy enriches the therapeutic
relationship and transforms it into a healing relationship.
• The therapeutic alliance also requires that the therapist must keep strict
confidentiality.

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• The therapist must not exploit the trust and the confidence of the client in
anyway. It is a professional relationship, and must remain so.

HOW IS EMPATHY DIFFERENT FROM

SYMPATHY AND INTELLECTUAL
UNDERSTANDING?
Empathy is different from sympathy and intellectual understanding of another
person’s situation.
In sympathy, one has compassion and pity towards the suffering of another
but is not able to feel like the other person.
Intellectual understanding is cold in the sense that the person is unable to
feel like the other person and does not feel sympathy either.
Empathy is present when one is able to understand the plight of another
person, and feel like the other person. It means understanding things from the
other person’s perspective, i.e. putting oneself in the other person’s shoes.

CLASSIFY THE DIFFERENT TYPES OF

THERAPIES BASED ON DIFFERENT
PARAMETERS.
What is the cause of the problem?
Psychodynamic therapy is of the view that intra-psychic conflicts, i.e. the
conflicts that are present within the psyche of the person, are the source of
psychological problems.
Behaviour therapy psychological problems arise due to faulty learning of
behaviours and cognitions.
Existential therapy postulate that the questions about the meaning of one’s
life and existence are the cause of psychological problems.

How the cause came into existence?

Psychodynamic therapy, unfulfilled desires of childhood and unresolved
childhood fears lead to intra-psychic conflicts.

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Behaviour therapy postulates that faulty conditioning patterns, faulty

learning, and faulty thinking and beliefs lead to maladaptive behaviours that
lead to psychological problems.
Existential therapy places importance on the present. It is the current
feelings of loneliness, alienation, sense of futility of one’s existence, etc., which
cause psychological problems.

Chief method of treatment

Psychodynamic therapy uses the methods of free association and reporting
of dreams to elicit the thoughts and feelings of the client. This material is
interpreted to the client to help her/him to confront and resolve the conflicts
Behaviour therapy identifies the faulty conditioning patterns and sets up
alternate behavioural contingencies to improve behaviour.
Existential therapy provides a therapeutic environment which is positive,
accepting, and non- judgmental. The client is able to talk about the problems
and the therapist acts as a facilitator. The client arrives at the solutions through
a process of personal growth.

Nature of therapeutic relationship

Psychodynamic therapy assumes that the therapist understands the client’s
intra-psychic conflicts better than the client.
Behaviour therapy assumes that the therapist is able to discern the faulty
behaviour and thought patterns of the client. It further assumes that the
therapist is capable of finding out the correct behaviour and thought patterns
Existential therapies emphasise that the therapist merely provides a warm,
empathic relationship in which the client feels secure to explore the nature and
causes of her/his problems by herself/himself.

Chief benefits of the treatment

Psychodynamic therapy values emotional insight as the important benefit
that the client derives from the treatment.
Behaviour therapy considers changing faulty behaviour and thought patterns
to adaptive ones as the chief benefit of the treatment.

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Humanistic therapy values personal growth as the chief benefit. Personal

growth is the process of gaining increasing understanding of oneself, and one’s
aspirations, emotions and motives.

Duration of the treatment

The duration of classical psycho- analysis may continue for several years.
However, several recent versions of psychodynamic therapies are completed in
10–15 sessions.
Behaviour and cognitive behaviour therapies as well as existential therapies are
shorter and are completed in a few months.

PSYCHODYNAMIC THERAPY
Psychodynamic therapy pioneered by Sigmund Freud is the oldest form of
psychotherapy. His close collaborator Carl Jung modified it to what came to be
known as the analytical psychotherapy.
Broadly, the psychodynamic therapy has conceptualised the structure of the
psyche, dynamics between different components of the psyche, and the source
of psychological distress.

Methods of eliciting the nature of intra-psychic conflict

Psychoanalysis has invented free association and dream interpretation as
two important methods for eliciting the intra-psychic conflicts.
The free association method is the main method for understanding the
client’s problems. Once a therapeutic relationship is established, and the client
feels comfortable, the therapist makes her/him lie down on the couch, close
her/his eyes and asks her/ him to speak whatever comes to mind without
censoring it in anyway. The client is encouraged to freely associate one thought
with another, and this method is called the method of free association. As the
therapist does not interrupt, the free flow of ideas, desires and conflicts of the
unconscious, which had been suppressed by the ego, emerge into the conscious
mind. This free uncensored verbal narrative of the client is a window into the
client’s unconscious to which the therapist gains access.
The client is asked to write down her/his dreams upon waking up.
Psychoanalysts look upon dreams as symbols of the unfulfilled desires present

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in the unconscious. The images of the dreams are symbols which signify intra-
psychic forces.
WHY ARE DREAMS USES SYMBOLS FOR MANIFESTATION?
Dreams use symbols because they are indirect expressions and hence would not
alert the ego. If the unfulfilled desires are expressed directly, the ever-vigilant
ego would suppress them and that would lead to anxiety.

Modality of treatment
Transference
As the unconscious forces are brought into the conscious realm through free
association and dream interpretation the client starts identifying the therapist
with the authority figures of the past, usually childhood. The therapist
maintains a non-judgmental yet permissive attitude and allows the client to
continue with this process of emotional identification. This is the process of
transference. The therapist encourages this process because it helps her/him
in understanding the unconscious conflicts of the client. The client acts out her/
his frustrations, anger, fear, and depression that s/he harboured towards that
person in the past, but could not express at that time. This stage is called
transference neurosis. A full-blown transference neurosis is helpful in
making the therapist aware of the nature of intra-psychic conflicts suffered by
the client.
There is the positive transference in which the client idolises, or falls in love
with the therapist, and seeks the therapist’s approval.
Negative transference is present when the client has feelings of hostility,
anger, and resentment towards the therapist.
The process of transference is met with resistance. Since the process of
transference exposes the unconscious wishes and conflicts.
Due to resistance, the client opposes the progress of therapy in order to protect
herself/himself from the recall of painful unconscious memories.
Resistance can be conscious or unconscious.
Conscious resistance is present when the client deliberately hides some
information.

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Unconscious resistance is assumed to be present when the client becomes

silent during the therapy session, recalls trivial details without recalling the
emotional ones, misses appointments, and comes late for therapy sessions.
Interpretation
It is the fundamental mechanism by which change is effected. Confrontation
and clarification are the two analytical techniques of interpretation.
In confrontation, the therapist points out to the client an aspect of her/his
psyche that must be faced by the client.
Clarification is the process by which the therapist brings a vague or confusing
event into sharp focus. This is done by separating and highlighting important
details about the event from unimportant ones.
Interpretation is considered to be the pinnacle of psychoanalysis.
The repeated process of using confrontation, clarification, and interpretation is
known as working through. Working through helps the patient to understand
herself/himself and the source of the problem and to integrate the uncovered
material into her/his ego.
The outcome of working through is insight. Insight is not a sudden event but a
gradual process wherein the unconscious memories are repeatedly integrated
into conscious awareness. Now, the client starts to understand herself/himself
better at an intellectual and emotional level, and gains insight into her/his
conflicts and problems. Insight is the end point of therapy as the client has
gained a new understanding of herself/himself.

Duration of treatment
Psychoanalysis lasts for several years, with one hour session for 4–5 days per
week.
There are three stages in the treatment.
Initial phase: the client becomes familiar with the routines, establishes a
therapeutic relationship with the analyst, and gets some relief with the process
of recollecting the superficial materials.
Middle phase: which is a long process. It is characterised by transference,
resistance on the part of the client, and confrontation and clarification, i.e.
working through on the therapist’s part. All these processes finally lead to
insight.

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Third phase: is the termination phase wherein the relationship with the analyst
is dissolved and the client prepares to leave the therapy.

BEHAVIOUR THERAPY
Behaviour therapies postulate that psychological distress arises because of faulty
behaviour patterns or thought patterns. It is, therefore, focused on the behaviour
and thoughts of the client in the present. The past is relevant only to the extent
of understanding the origins of the faulty behaviour and thought patterns. The
past is not activated or relived.
Behaviour therapy consists of a large set of specific techniques and
interventions. It is not a unified theory, which is applied irrespective of the
clinical diagnosis or the symptoms present. The symptoms of the client and the
clinical diagnosis are the guiding factors in the selection of the specific
techniques or interventions to be applied. The foundation of behaviour therapy
is on formulating dysfunctional or faulty behaviours, the factors which reinforce
and maintain these behaviours, and devising methods by which they can be
changed.

Method of treatment
Behavioural analysis is conducted to find malfunctioning behaviours, the
antecedents of faulty learning, and the factors that maintain or continue faulty
learning.
Malfunctioning behaviours are those behaviours which cause distress to the
client.
Antecedent factors are those causes which predispose the person to indulge
in that behaviour.
Maintaining factors are those factors which lead to the persistence of the
faulty behaviour.
Once the faulty behaviours which cause distress, have been identified, a
treatment package is chosen. The aim of the treatment is to extinguish or
eliminate the faulty behaviours and substitute them with adaptive behaviour

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patterns. The therapist does this through establishing antecedent operations

and consequent operations. Antecedent operations control behaviour by
changing something that precedes such a behaviour. The change can be done by
increasing or decreasing the reinforcing value of a particular consequence. This
is called establishing operation.

Behavioural Techniques
Negative reinforcement and aversive conditioning are the two major techniques
of behaviour modification.
1. Negative Reinforcement refers to following an undesired response with
an outcome that is painful or not liked.
2. Aversive conditioning refers to repeated association of undesired
response with an aversive consequence.
3. Positive reinforcement
4. Token economy persons with behavioural problems can be given a token
as a reward every time a wanted behaviour occurs. The tokens are collected
and exchanged for a reward such as an outing for the patient or a treat for
the child.
5. Unwanted behaviour can be reduced and wanted behaviour can be
increased simultaneously through differential reinforcement. Positive
reinforcement for the wanted behaviour and negative reinforcement for the
unwanted behaviour attempted together may be one such method. The
other method is to positively reinforce the wanted behaviour and ignore the
unwanted behaviour. The latter method is less painful and equally effective.
6. Systematic desensitisation is a technique introduced by Wolpe for
treating phobias or irrational fears. The client is interviewed to elicit fear-
provoking situations and together with the client, the therapist prepares a
hierarchy of anxiety-provoking stimuli with the least anxiety-provoking
stimuli at the bottom of the hierarchy. The therapist relaxes the client and
asks the client to think about the least anxiety-provoking situation. The
client is asked to stop thinking of the fearful situation if the slightest tension
is felt. Over sessions, the client is able to imagine more severe fear-

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provoking situations while maintaining the relaxation. The client gets

systematically desensitised to the fear.
7. The principle of reciprocal inhibition operates here. This principle
states that the presence of two mutually opposing forces at the same time,
inhibits the weaker force.
8. Modelling is the procedure wherein the client learns to behave in a certain
way by observing the behaviour of a role model or the therapist who
initially acts as the role model. Vicarious learning, i.e. learning by
observing others, is used and through a process of rewarding small changes
in the behaviour, the client gradually learns to acquire the behaviour of the
model.

COGNITIVE THERAPY
Cognitive therapies locate the cause of psychological distress in irrational
thoughts and beliefs.
Albert Ellis formulated the Rational Emotive Therapy (RET).
• The central thesis of this therapy is that irrational beliefs mediate between
the antecedent events and their consequences.
• The first step in RET is the antecedent- belief-consequence (ABC)
analysis.
• Antecedent events, which caused the psychological distress. The client is
also interviewed to find the irrational beliefs, which are distorting the
present reality. These beliefs are characterised by thoughts with ‘musts’ and
‘shoulds’. This distorted perception of the antecedent event due to the
irrational belief leads to the consequence, i.e. negative emotions and
behaviours.
• In the process of RET, the irrational beliefs are refuted by the therapist
through a process of non-directive questioning. The nature of
questioning is gentle, without probing or being directive. The questions make
the client to think deeper into her/his assumptions about life and problems.
The rational belief system replaces the irrational belief system and there is a
reduction in psychological distress.

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Another cognitive therapy is that of Aaron Beck.

• His theory of psychological distress characterised by anxiety or depression,
states that childhood experiences provided by the family and society develop
core schemas or systems, which include beliefs and action patterns in the
individual.
• Negative automatic thoughts are characterised by cognitive distortions.
Cognitive distortions are ways of thinking which are general in nature but
which distort the reality in a negative manner. These patterns of thought are
called dysfunctional cognitive structures. They lead to errors of
cognition about the social reality.
• The aim of the therapy is to achieve this cognitive restructuring which,
in turn, reduces anxiety and depression.
Similar to behaviour therapy, cognitive therapy focuses on solving a specific
problem of the client. Unlike psycho- dynamic therapy, behaviour therapy is
open, i.e. the therapist shares her/his method with the client. It is short, lasting
between 10–20 sessions.

COGNITIVE BEHAVIOUR THERAPY

The most popular therapy presently is the Cognitive Behaviour Therapy
(CBT).
• CBT is a short and efficacious treatment for a wide range of psychological
disorders such as anxiety, depression, panic attacks, and borderline
personality, etc.
• CBT adopts a bio- psychosocial approach to the delineation of
psychopathology. It combines cognitive therapy with behavioural
techniques.
• The rationale is that the client’s distress has its origins in the biological,
psychological, and social realms. Hence, addressing the biological aspects
through relaxation procedures, the psychological ones through behaviour
therapy and cognitive therapy techniques and the social ones with
environmental manipulations makes CBT a comprehensive technique
which is easy to use, applicable to a variety of disorders, and has proven
efficacy.

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HUMANISTIC- EXISTENTIAL THERAPY

The humanistic-existential therapies postulate that psychological distress
arises from feelings of loneliness, alienation, and an inability to find meaning
and genuine fulfilment in life. Human beings are motivated by the desire for
personal growth and self-actualisation, and an innate need to grow
emotionally. When these needs are curbed by society and family, human
beings experience psychological distress.
Healing occurs when the client is able to perceive the obstacles to self-
actualisation in her/his life and is able to remove them. Self-actualisation
requires free emotional expression.
The therapy creates a permissive, non- judgmental and accepting
atmosphere in which the client’s emotions can be freely expressed and the
complexity, balance and integration could be achieved.
The fundamental assumption is that the client has the freedom and
responsibility to control her/his own behaviour. The therapist is merely a
facilitator and guide. It is the client who is responsible for the success of
therapy. The chief aim of the therapy is to expand the client’s awareness.

Existential Therapy: Here and Now: Victor Frankl: Logotherapy

• Logos is the Greek word for soul and Logotherapy means treatment for the
soul.
• Frankl calls this process of finding meaning even in life-threatening
circumstances as the process of meaning making. The basis of meaning
making is a person’s quest for finding the spiritual truth of one’s existence.
• There is a spiritual unconscious, which is the storehouse of love, aesthetic
awareness, and values of life. Neurotic anxieties arise when the problems of
life are attached to the physical, psychological or spiritual aspects of one’s
existence.

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• Frankl emphasised the role of spiritual anxieties in leading to

meaninglessness and hence it may be called an existential anxiety, i.e.
neurotic anxiety of spiritual origin.
• The goal is to help the patients to find meaning and responsibility in their life
irrespective of their life circumstances. The therapist emphasises the unique
nature of the patient’s life and encourages them to find meaning in their life.
• In Logotherapy, the therapist is open and shares her/his feelings, values and
his/her own existence with the client. The emphasis is on here and now.
• Transference is actively discouraged.

Client Centered Therapy: Carl Rogers

• Rogers brought into psychotherapy the concept of self, with freedom and
choice as the core of one’s being.
• The therapist shows empathy, i.e. understanding the client’s experience as
if it were her/his own, is warm and has unconditional positive regard.
• Empathy sets up an emotional resonance between the therapist and the
client. Unconditional positive regard indicates that the positive warmth of
the therapist is not dependent on what the client reveals or does in the
therapy sessions. This unique unconditional warmth ensures that the client
feels secure and can trust the therapist.
• The reflection is achieved by rephrasing the statements of the client.
• This process of reflection helps the client to become integrated.
• This therapy helps a client to become her/his real self with the therapist
working as a facilitator.

Gestalt Therapy: Freiderick Perls and Laura Perls

• The German word gestalt means ‘whole’. The goal of gestalt therapy is to
increase an individual’s self-awareness and self- acceptance.
• The client is taught to recognise the bodily processes and the emotions that
are being blocked out from awareness.
• The therapist does this by encouraging the client to act out fantasies about
feelings and conflicts.

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• This therapy can also be used in group settings.

BIOMEDICAL THERAPY
Electro-convulsive Therapy (ECT) is a form of biomedical therapy. Mild
electric shock is given via electrodes to the brain of the patient to induce
convulsions.
• The shock is given by the psychiatrist only when it is necessary for the
improvement of the patient.
• ECT is not a routine treatment and is given only when drugs are not
effective in controlling the symptoms of the patient.

WHAT ARE THE FACTORS WHICH

CONTRIBUTE TO THE HEALING OF
PSYCHOTHERAPY?
1. A major factor in the healing is the techniques adopted by the therapist
and the implementation of the same with the patient/client.
2. The therapeutic alliance, which is formed between the therapist and the
patient/client, has healing properties, i.e, regular availability of the therapist,
and the warmth and empathy provided by the therapist.
3. The process of emotional unburdening is known as catharsis, and it has
healing properties.
4. Non-specific factors they occur across different systems of psychotherapy and
across different clients/patients and different therapists. Non-specific factors
attributable to the client/patient are motivation for change, expectation of
improvement due to the treatment, etc. These are called patient variables.
Non-specific factors attributable to the therapist are positive nature, absence of
unresolved emotional conflicts, presence of good mental health, etc. These are
called therapist variables.

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LIST DOWN THE ETHICS INVOLVED IN

PSYCHOTHERAPY
1. Informed consent needs to be taken.
2. Confidentiality of the client should be maintained.
3. Alleviating personal distress and suffering should be the goal of all attempts
of the therapist.
4. Integrity of the practitioner -client relationship is important.
5. Respect for human rights and dignity.
6. Professional competence and skills are essential.

ALTERNATIVE THERAPIES
Yoga is an ancient Indian technique detailed in the Ashtanga Yoga of Patanjali’s
Yoga Sutras. Yoga as it is commonly called today either refers to only the asanas or
body posture component or to breathing practices or pranayama, or to a
combination of the two. Yoga reduces the time to go to sleep and improves the
quality of sleep.
Meditation refers to the practice of focusing attention on breath or on an
object or thought or a mantra. Here attention is focused. In Vipasana
meditation, also known as mindfulness-based meditation, there is no fixed
object or thought to hold the attention. The person passively observes the
various bodily sensations and thoughts that are passing through in her or his
awareness. Prevention of repeated episodes of depression may be helped by
mindfulness- based meditation or Vipasana.
Sudarshana Kriya Yoga (SKY) is found to be a beneficial, low-risk, low-cost
adjunct to the treatment of stress, anxiety, post-traumatic stress disorder
(PTSD), depression, stress- related medical illnesses, substance abuse, and
rehabilitation of criminal offenders. SKY has been used as a public health
intervention technique to alleviate PTSD in survivors of mass disasters.
Kundalini Yoga taught in the USA has been found to be effective in treatment
of mental disorders. The Institute for Non- linear Science, University of
California, San Diego, USA has found that Kundalini Yoga is effective in the
treatment of obsessive- compulsive disorder. Kundalini Yoga combines pranayama

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or breathing techniques with chanting of mantras. This meditation would help

the patients to process emotional stimuli better and hence prevent biases in the
processing of these stimuli.

REHABILITATION OF MENTALLY ILL

The aim of rehabilitation is to empower the patient to become a productive
member of society to the extent possible.
Occupational therapy, social skills training, and vocational therapy. In
occupational therapy, the patients are taught skills such as candle making, paper
bag making and weaving to help them to form a work discipline.
Social skills training helps the patients to develop interpersonal skills
through role play, imitation and instruction. The objective is to teach the patient
to function in a social group. Cognitive retraining is given to improve the basic
cognitive functions of attention, memory and executive functions.
Vocational training is given wherein the patient is helped to gain skills
necessary to undertake productive employment.

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