Chapter 5

THERAPEUTIC APPROACHES
Introduction

• Psychological disorders can be stressful for the patient

and the family. It can puncture one’s optimal functioning
and hence accentuate the troubles/problems faced by
them.
• Psychotherapy is one of the ways to alleviate
psychological disorders and the distress caused by
them.
• There are various psychotherapies based on different
schools of psychology but all require a basic relationship
of trust and confidentiality.
 Nature & Process of Psychotherapy
• “Psychotherapy is a voluntary
relationship between the
client(seeking treatment) and
the therapist.”
Characteristics of psychotherapy:
• The goal/aim of psychotherapy is • Different theories use different
to solve the problems faced by principles to treat the clients.
• Psychotherapy needs to be
the client, changing maladaptive practiced by a trained
behaviours, decreasing the professional.
sense of personal distress and • Therapy involves a patient and a
help him/her to adapt better to client.
• The interaction between
the environment. therapist and client leads to a
therapeutic relationship which
aims for change.
 Betterment Better
Goals of Psychotherapy habits
Better thinking patterns

• Reinforcing client’s resort for betterment. Positive growth Self-awareness

• Lessening emotional pressure. Eased emotional
• Modifying habits. pressure
Better communication and
• Changing thinking patterns. relationships
• Unfolding the potential for positive growth. Better decision
making
• Increasing self awareness. Enhancing creativity Conscious choices
• Improving interpersonal relationships and
communication.
• Facilitating decision-making.
• Becoming aware of one’s choices.
• Being more creative and self aware.
Therapeutic Relationship/alliance

• Special relationship between the therapist and the client is known

as therapeutic relationship/alliance.
• It’s a contractual relationship where the therapist agrees to help the
clients overcome problems & is for a limited period of time.
• The relationship needs to be trusting and confiding. This ensures
the client is able to share his problems freely and unburden himself.
• The therapist needs to be acceptive of the clients behaviour, show
empathy and be warm and genuine towards the client. These are
the bases of a therapeutic relationship. A therapist should also
maintain confidentiality of the client.
Steps in formulation of a client’s problems

Understanding of the Identifying areas of

Choice of technique
problem problems
• Knowing the problem • Identifying the goals • Therapist decides on
areas of therapy by the technique of
• Understanding the understanding the therapy to be used
distress caused by target areas. which is dependent
the problems. on the therapist’s
training.
• Accordingly, the
goals of therapy,
duration of
treatment etc are
decided.

The clinical formulation is a ongoing process. As the time passes, the therapist
receives in-depth information about the client and his/her background and
family.
Type of therapies
Psychodynamic Therapy Pioneered by Sigmund Freud

Carl Jung made a few

modifications in his
treatment and called
his therapy as
analytical
psychotherapy

Psychodynamic psychotherapy analyses

clients in terms of their structure of
personality(Id,Ego,Supergo) & the dynamics
between these structures (defense
mechanisms used) and the source/cause of
distress (laid in the first few years of
development)
Methods in psychoanalytic psychotherapy
• Eliciting intrapsychic conflicts
through DREAM INTERPRETATION
and FREE ASSOCIATION
• Free association is a techniques
wherein the client is made to say
whatever comes to his mind without
filtering it or censoring anything.
The client is encouraged to freely
associate one thought with another.
This free uncensored verbal
narrative becomes a window to the
client’s unconscious.
Methods in psychoanalytic psychotherapy

• Dream Interpretation- Psychoanalysis

looks at dreams as the royal road to
unconscious. They are viewed as
symbols of the unfulfilled desires in the
unconscious. Dreams convert the
desires into a symbol and thus doesn’t
alert the ego.
• In psychoanalytic psychotherapy, the
client is encouraged to take note of
his/her dreams which the therapist
later interprets.
Modality of treatment
• Transference and interpretation are the
methods of treatment in
psychoanalysis.
• As the unconscious unfolds itself
through the methods of dream analysis
and free association, the client starts
to identify the therapist with the
people in his/her past (Mother/father).
This process of emotional identification
of the client with their therapist is
known as TRANSFERENCE.
When the client acts out the feelings of the
past harboured towards that particular
person in the session towards the
therapist, the process is called
Transference neurosis.
Transference (Mode of treatment)

• Transference neurosis helps the therapist see the client’s intrapsychic conflicts more
clearly.
Transference exposes the
unconscious desires and wishes of
the client, which alerts the ego
Transference guards and the clients sometimes
begin to show resistance.
Resistance can be
Confrontation
Positive (Client Negative (Client conscious or unconscious in
is used to
idolises or falls in feels hostile, nature. Conscious
love with anger towards the deal with the
resistance expresses itself
therapist) therapist) resistance
in forms of hiding
the client
information from the
shows.
therapist. Unconscious
resistance can be noted
when the client goes silent
in sessions, misses the
Interpretation (Mode of treatment)
• Psychoanalysts use interpretation by and large for changing the
client’s feelings/attitudes/behaviour. It is considered to be the
pinnacle of psychoanalysis.
• Interpretation involves Confrontation and Clarification
The repeated process of
using confrontation,
clarification and
interpretation is known
Interpretation as “WORKING
THROUGH”

Working through
helps in the
Clarification Confrontation development of
A vague or confusing The therapist insight.
event is made sense confronts the client In psychoanalysis, the "insight" is a
of and brought to with the conflicts of sort of "clear understanding", but this is
focus. the psyche.
related to a kind of a feeling of liberation
as from a psychical burden.
Psychoanalytic Psychotherapy (At a glance)
Psychoanalytical Psychotherapy

Modes of eliciting intrapsychic

Modality of treatment
conflicts

Transference Interpretation
Dream (Positive & Negative;
Free association Interpretation (Confrontation and
Transference Clarification)
neurosis)

Working
Resistance
through
Insight
Stages of psychoanalytic therapy (Duration of therapy)
• Therapeutic relationship is formed/ Rapport formation
Initi • Client becomes familiar with process.
al • Basic details and information about the subject is pursued.
Pha
se

• Free association; Dream interpretation

• Resistance and transference on the part of client
Mid
dle • Interpretation-Clarification and confrontation on the part of the
Pha therapist.
se

Ter • Relationship dissolves

min
atio
• Client is prepared to leave therapy.
n
Pha
se
Behaviour Therapy
Introduction to Behaviour therapy

• Understands distress as coming from

learnt faulty/maladaptive behaviour.

• Basic assumption is that the

maladaptive behaviour can be
corrected through adequate learning
processed.

• The foundation of behaviour therapy is

on identifying dysfunctional or faulty
behaviours, the factors which maintain
or reinforce such behaviours and
devising methods through which these
can be changed.
 Method of treatment
• Behavioural analysis is done by:

Recognizing
Identifying the Identifying
maladaptive antecedent of the
behaviours the behaviour maintaining
(cause/origin) factors

Aim of the treatment to is eliminate the faulty

behaviour & substitute them with adaptive patterns.
Antecedent operations- You change
the behaviour by changing
something that precedes the
behaviour.
Done by establishing ANTECEDENT Consequent operation_ You give
OPERATIONS & CONSEQUENT OPERATIONS them positive
feedback/reinforcement for
engaging in a new behaviour.
Behavioural techniques
• First step is to reduce the arousal level of the
client. Done by inducing relaxation to the patient.
• Wide range of techniques used in Behaviour
therapy:
Negative reinforcement
 Aversive Conditioning
Positive reinforcement
Token economy
Systematic desensitization
Modelling
Behaviour therapy techniques

Negative reinforcement: Undesired Aversive Conditioning: Repeated Positive reinforcement: A

response if followed by a undesirable association of an undesired response favourable behaviour/response if
outcome. with an aversive consequence. followed by a desirable outcome

Systematic desensitization: Given

by Wolpe. A hierarchy of anxiety
provoking situation is created-
Token economy: using tokens as Relaxation is induced-client is made to Modelling: Client learns to behave in
rewards which can be later converted visualize the anxiety provoking a certain way by observing behaviour
to a desired reward. situations from least threatening ones of a role model.
to most threatening ones from the
hierarchy. Client gets systematically
desensitized of the fear.
Additional terms in behaviour therapy
• Differential reinforcement- In this
method, positive reinforcement if
given to the wanted behaviour
and negative reinforcement or
ignorance is given to the
unwanted behaviour.
• The principle of reciprocal
inhibition: It states that the
presence of two mutually
opposing forces at the same time
inhibits the weaker force. It is a
part of the technique of
systematic desensitization.
Cognitive Therapy

• They believe that psychological distress is a result of

irrational thoughts and beliefs.
• The aim of cognitive therapies is to convert these
distorted ways of thinking with more realistic thoughts.
• Comparatively new therapy.
• The treatment is imparted within a short span of time.
• Popularly used with Depression, anxiety, OCD and other
mental disorders.
Albert Ellis- Rational Emotive Therapy
(RET)
The theory behind this
therapy views irrational
beliefs to be mediating
between antecedent event
and the consequence.

Antecedent event is the

cause of the psychological
distress.
Irrational beliefs are the
beliefs characterised by
‘musts’, ‘should’.
Consequence is a
maladaptive behaviour.
 RET (Continued)
• The first step in RET is to do ABC analysis that is: Antecedent-Belief-
Consequence analysis
• The distorted perception of the antecedent event leads to consequence.
[Irrational belief (B)] [ Antecedent (A)] [Consequence (C)]
• Irrational beliefs are assessed through questionnaires and interviews.
RET
RET

• The therapist works on/refutes the irrational thoughts by

non-directive questioning (gentle, indirect probing).
• This makes the client think deeper about his beliefs and
he is able to change them.
• The rational belief system replaces the irrational belief
system at the end of the therapy.
Aaron Beck’s Cognitive Therapy (CT)

• Core schemas are developed in the childhood which consists

of beliefs and action patterns for the individuals.
• These core schemas get stronger as one grows up facing
situations that coincide with the core schema. This leads to
development of cognitive distortions or dysfunctional cognitive
structures.
• When these dysfunctional cognitive structures get
reinforced/stronger over time, it leads to depression, anxiety &
other mental disorders.
• Therapist works towards cognitive restructuring.
CBT continued
Cognitive Behaviour Therapy (CBT)

• Short and effective treatment for a number of disorders.

• Adopts a bio-psycho-social approach
• Addresses the :
biological aspects of distress through relaxation,
the psychological ones through behaviour therapy ,and
the social aspects of distress with environmental
manipulations
 Cognitive Therapy at a glance
• Given by Albert Ellis
Rational Emotive • ABC analysis (Activating event-Belief-Consequence)
• Irrational beliefs characterized by ‘musts’ & ‘should’ are changed by
Therapy/REBT using non directive questioning.

• Given by Aaron Beck.

Cognitive • Core schemas are formulated in the childhood. These carry beliefs
and create dysfunctional cognitive structures as one grows up.
Therapy • Cognitive restructuring is aimed in therapy.

Cognitive • Client’s distress is because of distress in Biological, psychological &

social realms.
Behaviour • Biological distress is handled by relaxation, psychological distress
by behavioural techniques & Social distress is managed by
therapy environmental manipulations.
Humanistic existential Therapy
Self actua
• According to humanistic-existential lisation is
an innate
model, distress is a result of /inborn
force tha
t moves t
feelings of loneliness, alienation & person to
become
he
inability to find meaning in life. more com
plex,
balanced
• These feelings originate when the &
integrate
d.
society curbs an individual’s needs
In hum
for growth and self-actualisation a ni st i c
the per the
son is h rapy,
perceiv elped t
e these o
to self-a o b
ctualisa stacles
remove t i o n an
them. d

Frustration of self actualisation causes

distress.
 Existential Therapy

• Propounded by victor Frankl-called it LOGO therapy.

• Logo means soul- so this therapy is “treatment for the
soul”
• He claimed that there exists a spiritual unconscious
which is a storehouse of love, aesthetic awareness &
values.
• Spiritual/existential anxieties lead one to feel
meaningless
• The goal of logotherapy is to help patients find
meaning and responsibility in their lives despite their
circumstances.
• This process of finding meaning in life is known as
meaning making.
Existential Therapy continued…

• In Logotherapy, the therapist emphasizes the unique

nature of the patient’s life & encourages them to find
meaning.
• The therapist is open and shares his feelings, values
and existence with the client.
• The goal is to facilitate the client to find the meaning of
his/her life.
• Transference is actively discouraged.
Client-centred Therapy
Empathy is shown by the therapist to
• Given by Carl Rogers. the client which helps in setting up
emotional resonance/connection
• As per Rogers, at the between client & therapist.
core of one’s being is the
Unconditional positive regard helps
self with freedom and the client feel secure which help him
choice. delve into his own feelings
• In therapy, the client’s
disintegrated self is The therapist reflects on client’s
feelings in a non-judgemental way
worked upon by the use either by rephrasing them or by
of Empathy, non- seeking simple clarifications
judgementalism and
unconditional positive This reflection helps the client become
regard. more integrated and centred and the
client is able to become his/her real
self.
 Gestalt Therapy

• Was proposed by Frederick Perls & Laura

Perls.
• Goal of this therapy is to increase client’s
self awareness and self acceptance.
• The client is made to recognise the
blocked emotions and bodily sensations
which is done by encouraging him to act
out his conflicts, fantasies and feelings.
• This kind of therapy is also used in group
setting rather than happening one on
one.
Humanistic-Existential therapies at a glance

Client Centred Gestalt

Logo Therapy
therapy therapy
Distress is caused when the
One’s important elements of Goal is to increase client’s
society doesn’t let one look
being are Self, freedom & self-awareness and self-
for meaning and
choice. acceptance.
responsibilities in one’s life.

Disintegrated self is
integrated through the use of Therapist encourages the Done by encouraging the
empathy, non judgementalism client to find the meaning of client to act out his feelings,
and unconditional positive his unique existence. conflicts and fantasies.
regard
Factors leading to healing in therapy

Therapeutic alliance
between the client & Catharsis or
therapist, emotional
unburdening

Patient variables-
Motivation for
Therapy techniques change,
used by the therapist Therapist variables-
Positive nature,
absence of his own
conflicts
Ethics in psychotherapy

• Informed Consent
• Confidentiality of the client
• Goal of therapy is to alleviate distress.
• Integrity in the therapeutic relationship.
• Respect for human rights & dignity.
• Professional competence.
Alternative therapies

• Yoga- An ancient Indian technique. All about body postures &

breathing practices/pranayama.
• Meditation- Focussing you attention on an object or thought or
breathing. Mindfulness based meditation (Vipasana
meditation)is an meditation where a person generally observes
his/her bodily sensations and thoughts & be a witness to it.
• Sudarshana Kriya Yoga (SKY)is a rapid breathing technique found
to be effective with PTSD, anxiety, stress related disorders
• Research backs up the use of these alternative therapies in
effectively treating or preventing people from various disorders.
Rehabilitation of the mentally ill

• The aim of rehabilitation is to empower the patient to

become a productive member of the society.
• Rehabilitation is required for people suffering from
severe disorders-depression, schizophrenia, anxiety etc
because there are a variety of negative symptoms
associated with these conditions.
• Rehabilitation involves- OCCUPATIONAL THERAPY,
SOCIAL- SKILLS THERAPY & VOCATIONAL THERAPY