CHAPTER-5 : THERAPEUTIC APPROACHES

Nature of Psychotherapy
Psychotherapy is a voluntary relationship between the one seeking treatment or the client and the one
who treats or the therapist.

Characteristics of Psychotherapy
All psychotherapeutic approaches have the following characteristics :

(i) Systematic application of principles underlying the different theories of therapy,

(ii) Persons who have received practical training under expert supervision can practice
psychotherapy, and not everybody. An untrained person may unintentionally cause more
harm than any good.
(iii) The therapeutic situation involves a therapist and a client who seeks and receives help for
her/his emotional problems (this person is the focus of attention in the therapeutic
process).
(iv) The interaction of these two persons — the therapist and the client — results in the
consolidation/formation of the therapeutic relationship. This is a confidential, interpersonal,
and dynamic relationship.
(v) This human relationship is central to any sort of psychological therapy

GOALS OF PSYCHOTHERAPY-
Psychotherapies aim at changing the maladaptive behaviours, decreasing the sense of personal distress,
and helping the client to adapt better to her/his environment. Various psychotherapies aim at the
following goals :

❖ Reinforcing client’s resolve for betterment.

❖ Lessening emotional pressure.

❖ Unfolding the potential for positive growth.

❖ Modifying habits.

❖ Changing thinking patterns.

❖ Increasing self-awareness.

❖ Improving interpersonal relations and communication. (viii)Facilitating decision-making.

❖ Becoming aware of one’s choices in life.

❖ Relating to one’s social environment in a more creative and self-aware manner.

Therapeutic Relationship

❖ The special relationship between the client and the therapist is known as the therapeutic
relationship or alliance.
❖ The purpose of the relationship is to help the client to solve the psychological problems being
faced by her or him
❖ There are two major components of a therapeutic alliance.
i) The first component is the 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.
ii) The second component of therapeutic alliance is the 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 :
This relationship has several unique properties –

1) TRUST- This relationship is a trusting and confiding relationship. The high level of trust
enables the client to unburden herself/himself to the therapist and confide her/his
psychological and personal problems to the latter.
● The therapist encourages this by being: -
- Accepting
- Empathic
- Genuine
- Warm to the client

2) UNCONDITIONAL POSITIVE REGARD -

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.

3) EMPATHY –
The therapist has empathy for the client. 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. Empathy enriches the therapeutic relationship and transforms it into a
healing relationship.

4 ) CONFIDENTIALITY –

The therapeutic alliance also requires that the therapist must keep strict confidentiality of the
experiences, events, feelings or thoughts disclosed by the client. The therapist must not exploit
 the trust and the confidence of the client in any way.

TYPE OF THERAPIES-
All psychotherapies aim at removing human distress and fostering effective behaviour, they differ
greatly in concepts, methods, and techniques.

Psychotherapies may be classified into three broad groups, viz. the psychodynamic, behaviour, and
existential psychotherapies.

The classification of psychotherapies is based on the following parameter s:

Parameters Psychodynamic Behaviour Cognitive Humanistic-
Therapies Therapies Therapies existential
therapies
Causes of the Intrapsychic Faulty learning of Faulty learning of Meaning of one’s
Problem conflicts are the behaviours cognitions. life and existence
source of are the cause of
psychological psychological
problems. problems.
How cause Unfulfilled desires of Faulty Faulty thinking Feelings of
come into childhood and conditioning and beliefs lead to loneliness,
unresolved patterns, faulty maladaptive alienation, sense
existence childhood fears lead learning lead to behaviours of futility of one’s
to intrapsychic maladaptive existence, etc.
conflicts. behaviours. cause
psychological
problems.
Chief method Free association Identifies the The cognitive It provides a
of treatment method and dream- faulty methods therapeutic
analysis to elicit the conditioning employed to environment wich
thoughts and patterns and sets challenge the is positive,
feelings of the client up alternate faulty thinking achcepting, and
behavioural patterns to help nonjudgmental to
contingencies to the client to attain personal
improve overcome growth.
behaviour. psychological
distress.
Nature of the The therapist The therapist is The therapist is Therapist
therapeutic understands the able to discern able to discern provides a warm,
client’s intrapsychic the faulty faulty thought empathic
relationship conflicts and behaviour It patterns of the relationship in
interprets the further assumes client. Therapist is which the client
thoughts and that the therapist capable of finding feels secure to
feelings to the is capable of out the correct explore the
client finding out the thought patterns nature of the
correct behavior. for the client. problems by
 himself.
Chief benefit values emotional changing faulty changing faulty It values personal
to the client insight as the behaviour to thought patterns growth as the
important benefit . adaptive ones as to adaptive ones chief benefit.
the chief benefit as the chief Personal growth is
of the treatment. benefit of the the process of
treatment.
kgaining
increasing
understanding of
oneself.
Duration of It may continue for These are shorter These are shorter These are shorter
the treatment several years. Now and are and are and are
recent versions of completed in few completed in few completed in few
psychodynamic months. months. months.
therapies are
completed in 10–15
sessions.

Behaviour Therapy

● Behaviour therapies postulate that psychological distress arises because of faulty behaviour
patterns or thought patterns.
● It is 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 clinical application of learning theory principles constitute behaviour therapy.

Method of Treatment

❖ The client with psychological distress or with physical symptoms, which cannot be attributed to
physical disease, is interviewed with a view to analyse her/his behaviour patterns.

❖ 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.Behavioural analysisis conductedto identify the faulty behaviours which
cause distress, then a treatment package is chosen.

❖ The aim of the treatment is to extinguish or eliminate the faulty behaviours and substitute them
with adaptive behaviour 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 -
A range of techniques is available for changing behaviour. The principles of these techniques are to
reduce the arousal level of the client, alter behaviour through classical conditioning or operant
conditioning with different contingencies of reinforcements, as well as to use vicarious learning
procedures

1) Negative reinforcement and aversive conditioning are the two major techniques of behaviour
modification. Responses that lead organisms to get rid of painful stimuli or avoid and escape
from them provide negative reinforcement.

2) Aversive conditioning - refers to repeated association of undesired response with an

aversive consequence
3) Positive reinforcement- is given to increase the deficit. For example, if a child does not do
homework regularly, positive reinforcement may be used by the child’s mother by preparing
the child’s favourite dish whenever s/he does homework at the appointed time. The positive
reinforcement of food will increase the behaviour of doing homework at the appointed time.

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. . This is known as token economy.

5) Differential reinforcement- Unwanted behaviour can be reduced and wanted behaviour can
be increased simultaneously. 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 desensitization –
This is a technique introduced by Wolpe for treating phobias or irrational fears.
 The client is interviewed to elicit fearprovoking 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 provoking situations while
maintaining the relaxation. The client gets systematically desensitised to the fear.

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.

Thus, the relaxation response is first built up and mildly anxiety-provoking scene is imagined,
and the anxiety is overcome by the relaxation. The client is able to tolerate progressively greater
levels of anxiety because of her/his relaxed state.

7) 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.

Cognitive Therapy

● Cognitive therapies locate the cause of psychological distress in irrational thoughts and beliefs.

● Albert Ellis formulated the Rational Emotive Therapy (RET).

1. The central thesis of this therapy is that irrational beliefs mediate between the
antecedent events and their consequences.
2. The first step in RET is the antecedentbelief-consequence (ABC) analysis. Antecedent
events, which caused the psychological distress, are noted. The client is also
interviewed to find the irrational beliefs, which are distorting the present reality.
Irrational beliefs may not be supported by empirical evidence in the environment.
These beliefs are characterised by thoughts with ‘musts’ and ‘shoulds’, i.e. things ‘must’
and ‘should’ be in a particular manner. Examples of irrational beliefs are, “One should
be loved by everybody all the time”, “Human misery is caused by external events over
which one does not have any control”, etc.
3. This distorted perception of the antecedent event due to the irrational belief leads to
the consequence, i.e. negative emotions and behaviours. Irrational beliefs are assessed
through questionnaires and interviews.
4. 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. Gradually the client is able to change the
irrational beliefs by making a change in her/his philosophy about life. The rational belief
 system replaces the irrational belief system and there is a reduction in psychological
distress.

❖ Another cognitive therapy is that of Aaron Beck.

1. His theory of psychological distress characterised by anxiety or depression, states that
childhood experiences provided by the family and society develop core schemasor
systems, which include beliefs and action patterns in the individual.
2. Thus, a client, who was neglected by the parents as a child, develops the core schema of
“I am not wanted”. During the course of life, a critical incident occurs in her/his life. S/he
is publicly ridiculed by the teacher in school. This critical incident triggers the core
schema of “I am not wanted” leading to the development of negative automatic
thoughts.
3. Negative thoughts are persistent irrational thoughts such as “nobody loves me”, “I am
ugly”, “I am stupid”, “I will not succeed”, etc. Such negative automatic thoughts are
characterisedby cognitive distortions.
4. 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. Repeated
occurrence of these thoughts leads to the development of feelings of anxiety and
depression.
5. The therapist uses questioning, which is gentle, nonthreatening disputation of the
client’s beliefs and thoughts. Examples of such question would be, “Why should
everyone love you?”, “What does it mean to you to succeed?”, etc. The questions make
the client think in a direction opposite to that of the negative automatic thoughts
whereby s/he gains insight into the nature Psychology of her/his dysfunctional schemas,
and is able to alter her/his cognitive structures.
6. The aim of the therapy is to achieve this cognitive restructuring which reduces anxiety
and depression. It is short, lasting between 10–20 sessions.

❖ Cognitive Behaviour Therapy

1. The most popular therapy presently is the Cognitive Behaviour Therapy (CBT). Research
into the outcome and effectiveness of psychotherapy has conclusively established CBT
to be a short and efficacious treatment for a wide range of psychological disorders such
as anxiety, depression, panic attacks, and borderline personality, etc.
2. CBT adopts a biopsychosocial 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.

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.

Self-actualisation is defined as an innate or inborn force that moves the person to become more
complex, balanced, and integrated, i.e. achieving the complexity and balance without being fragmented.
Integrated means a sense of whole, being a complete person.

Healing occurs when the client is able to perceive the obstacles to selfactualisation in her/his life and is
able to remove them. Self-actualisation requires free emotional expression.

The therapy creates a permissive, nonjudgmental 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
Victor Frankl, a psychiatrist and neurologist propounded the 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. Just as
there is an unconscious, which is the repository of instincts , 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.
Franklemphasised 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 of logotherapy 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

The goal is to facilitate the client to find the meaning of her/his being.

Client-centred Therapy
Client-centred therapy was given by Carl Rogers.

Rogers combined scientific rigour with the individualised practice of clientcentred psychotherapy.
Rogers brought into psychotherapy the concept of self, with freedom and choice as the core of one’s
being.

The therapy provides a warm relationship in which the client can reconnect with her/his disintegrated
feelings. 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, i.e. total acceptance of the client as s/he is.
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
client feels secure enough to explore her/his feelings. The therapist reflects the feelings of the client in a
nonjudgmental manner. The reflection is achieved by rephrasing the statements of the client, i.e.
seeking simple clarifications to enhance the meaning of the client’s statements. Personal relationships
improve with an increase in adjustment.

The therapy helps a client to become her/his real self with the therapist 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 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.

Factors Contributing to Healing in Psychotherapy

 As we have read, psychotherapy is a treatment of psychological distress. There are several factors which
contribute to the healing process. Some of these factors are as follows :

1. A major factor in the healing is the techniques adopted by the therapistand the implementation of
the same with the patient/client. If the behavioural system and the CBT school are adopted to heal an
anxious client, the relaxation procedures and the cognitive restructuring largely contribute to the
healing.

2. The therapeutic alliance, which is formed between the therapist and the patient/client, has healing
properties, because of the regular availability of the therapist, and the warmth and empathy provided
by the therapist.

3. At the outset of therapy while the patient/client is being interviewed in the initial sessions to
understand the nature of the problem, s/he unburdens the emotional problems being faced. This
process of emotional unburdening is known as catharsis, and it has healing properties.

4. There are several non-specific factors associated with psychotherapy. Some of these factors are
attributed to the patient/client and some to the therapist. These factors are called non-specific because
they occur across different systems of psychotherapy and across different clients/patients anddifferent
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

Ethics in Psychotherapy
Some of the ethical standards that need to be practiced by professional psychotherapists are :

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

● Alternative therapies are alternative treatment possibilities to the conventional drug treatment
or psychotherapy.
 ● There are many alternative therapies such as yoga, meditation, acupuncture, herbal remedies
and so on. In the past 25 years, yoga and meditation have gained popularity as treatment
programmes for psychological distress.

1) 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.

2) Meditation refers to the practice of focusing attention on breath or on an object or thought or

a mantra. 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.

3) SudarshanaKriya Yoga (SKY) The rapid breathing techniques to induce hyperventilation as in

i) SudarshanaKriya 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. Ii)
ii) SKY has been used as a public health intervention technique to alleviate PTSD in
survivors of mass disasters. Yoga techniques enhance well-being, mood, attention,
mental focus, and stress tolerance. Proper training by a skilled teacher and a 30-minute
practice every day will maximise the benefits.
iii) Research conducted at the National Institute of Mental Health and Neurosciences
(NIMHANS), India, has shown that SKY reduces depression. Further, alcoholic patients
who practice SKY have reduced depression and stress levels. Insomnia is treated with
yoga. Yoga reduces the time to go to sleep and improves the quality of sleep.

4) Kundalini Yoga - taught in the USA has been found to be effective in treatment of mental
disorders. The Institute for Nonlinear Science, University of California, San Diego, USA has found
that Kundalini Yoga is effective in the

Rehabilitation Of The Mentally ill-

Treatment of psychological disorders Reduction of symptoms Improvement of quality of life

The treatment of psychological disorders has two components, i.e.

i) reduction of symptoms.
ii) improving the level of functioning or quality of life.

● In the case of milder disorders such as generalised anxiety, reactive depression or phobia,
reduction of symptoms is associated with an improvement in the quality of life. However, in
 the case of severe mental disorders such as schizophrenia, reduction of symptoms may not be
associated with an improvement in the quality of life.

● Many patients suffer from negative symptoms such as disinterest and lack of motivation to do
work or to interact with people.

● Rehabilitation is required to help such patients become self-sufficient. The aim of

rehabilitation is to empower the patient to become a productive member of society to the
extent possible.

● In rehabilitation, the patients are given: -

1) Occupational therapy (the patients are taught skills such as candle making, paper bag
making and weaving to help them to form a work discipline)
2) Social skills training (the patients develop interpersonal skills through role play, imitation
and instruction. The objective is to teach the patient to function in a social group)
3) Cognitive retraining is given to improve the basic cognitive functions of attention, memory
and executive functions (cognitive restructuring occurs). - Vocational therapy (the patient is
helped to gain skills necessary to undertake productive employment.

______________________________________________________________________________