Chapter 5

Therapeutic Approaches
Nature & process of Psychotherapy
 A voluntary relationship between one seeking treatment (client) and the one who treats (therapist) to solve
the psychological problem being faced by the client
 To change the maladaptive behaviour
 Decreasing distress
 To make him better adaptive to his environment
Goals of psychotherapy
 Betterment of client
 Lessening emotional pressure
 Unfolding the potential for positive growth.
 Modifying habits
 Modifying thoughts
 Increasing self awareness
 Improving interpersonal relationship.
 Facilitating decision –making
Therapeutic relationship or alliance
 The special relationship between the client and the therapist
 Neither a passing acquaintance nor a permanent relationship.
Major component of therapeutic alliance
 Contractual nature –to solve the client problem
 Limited duration-alliance lasts until the client resolved his problems
 Characteristics of psychotherapy
 Systematic application of principles underlying theories of therapy.
 Those who got enough training can only do therapy
 It involves a therapist and the client.
 It involves interaction of these two persons.
 High level of trust & Confidentiality
Unconditional positive regard:-

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 Therapist is not judging the client and will show the positive feeling towards the client even if the client is rude
or ventilate all the wrongs he had done or thought.
- Just accepting the clients feeling
- I understand----but you should not
Empathy
 Intellectual understanding of another person's situation
 Feel like the other persons feeling.
 Understanding things from the other persons view point
 Putting oneself in the other person’s shoes.
 It enriches therapeutic relationship.

Types of therapies
 Psychodynamic therapy
 Behavioural therapy
 Existential therapy
 Classification of psychotherapies is based on the following parameters

 Based on the cause of the disorder

Psychodynamic-intrapsychic conflicts ( conflict that are present within the psyche of the person)
Behaviour therapy: faulty learning of behaviour.
Existential therapy: from birth we have total freedom to give meaning to our life existence. Those who avoid this
responsibility becomes dysfunctional
 How did the cause come in to existence
Psychodynamic:-unfulfilled desires of childhood & unresolved childhood fears lead to intrapsychic conflicts.
Behaviour therapy:- Faulty learning and faulty thinking.
Existential therapy: feeling of loneliness, alienation, sense of futility of one’s existence.
 Based on the chief method of treatment
Psychodynamic therapy: method of free association, dream analysis.
Behaviour therapy: faulty behavioural patterns can be relearned through counter conditioning.
Existential therapy; provides a therapeutic environment which is positive . Accepting and non-judgmental. Therapist
act as a facilitator for personal growth.
 Based on the nature of therapeutic relationship:-
 Psychodynamic: Therapists understands the clients intrapsychic conflicts than the client.
 Behaviour therapy: therapist is capable of finding out the correct behaviour and the thought pattern , which

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would be adaptive for the client.

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  Existential therapy: Therapist just provides a warm. Empathetic relationship in which the client feel secure to
explore the nature and causes of his problem.
 Based on the chief benefit of the client
 Psychodynamic therapy: emotional insight ( understand his conflict intellectually) is the chief n\benefit.
 Behavioural therapy: client can relearn adaptive behaviour.
 Existential therapy;-personal growth (gaining increasing understanding of oneself, emotions and motives.
 Based on the duration of the treatment.
 Psychodynamic therapy; may continue for several years. But recent version of therapies are completed in 10-
15 sessions.
 Behavioural and existential: shorter and are completed in a few months.
 The process of psychotherapy begins by formulating clients problem.

Steps in formulating client’s problem:

1. Understanding of the problem:-therapist able to understand the actual distress experienced by the client

2. Identification of the areas to be targeted for treatment:- Eg: inability to hold a job and report inability tom face

superiors. target behaviour: increase assertiveness.

3. Choice of method of treatment;-depend on which technique the therapist got training, time etc.

1. Behaviour therapy
 Principle:-psychological distress arises because of learning faulty behaviour pattern or thought pattern.
 Therefore it focused on the behaviour and thoughts of the client.
 The past is not revealed or activated, but only the faulty patterns are corrected in the present.
 It include the application of learning principles ( classical conditioning, operant learning, social learning, etc).
 It include a large number of different techniques ( eg:-relaxation technique, aversive therapy etc)
 The selection of technique depend up on symptoms and diagnosis) Eg-a depressed patient would be treated
differently from a client who is anxious)
Method of treatment
 Client is interviewed to understand his / her faulty or malfunctioning behavioural (faulty) pattern, antecedents
& maintaining factors ( case study- Observation, interview etc).
 Malfunctioning behaviour:- those behaviour which cause distress to the client.
 Antecedent factors:-causes of this malfunctioning behaviour.
 Maintaining factor;- factors which lead to the continuity of the malfunctioning behaviour
Eg:-A boy who has acquired the habit of smoking (faulty behaviour) and seeks help to get rid of smoking. He started
smoking when he was preparing for examination (antecedent) to relieve tension (maintaining factor)

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 Once the faulty behaviours which cause distress, have been identified, a treatment package is chosen

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 The aim of the treatment is to eliminate the faulty behaviour with adaptive behaviour.
 It includes antecedent operation & consequent operation.
 Antecedent operations:- control behaviour by changing something that precede such a behaviour.
 Change can be done increasing or decreasing reinforcing value of a particular consequence ( establishing
operation)
 Eg:- if a child gives trouble in eating dinner-establishing operation is to decrease the quantity of food served
at tea time to increase the hunger at food time.
 Consequent operation:-praising the child for food eating
Behavioural Techniques
 It applies Learning principles-classical conditioning, operant conditioning, observational learning ( vicarious
learning)

a. Negative reinforcement:-Negative reinforcement occurs when a certain stimulus (usually an aversive stimulus)
is removed after a particular behavior is exhibited. The likelihood of the particular behavior occurring again in
the future is increased because of removing/avoiding the negative consequence.

 Negative reinforcement should not be thought of as a punishment procedure. With negative reinforcement,
you are increasing a behavior, whereas with punishment, you are decreasing a behavior.
 taking something negative away in order to increase a response.
 Eg:- Child eats well if the bitter taste of food is removed.
 When thinking about reinforcement, always remember that the end result is to try to increase the behavior,
 Whereas punishment include adding something negative to decrease a behaviour ( beating a child for
misbehaving).
 For positive reinforcement, adding something positive in order to increase a response (give chocolate then he
studies well)
 . For negative reinforcement, think of it as taking something negative away in order to increase a response.

b. Aversive conditioning:- repeated association of undesired response with an aversive consequence.

Eg:- an alcoholic is given a mild shock and asked to smell the alcohol.

c. Positive reinforcement:-to increase the deficit behavior.

Eg:- whenever the child do his home work , reinforcement is given in the form of his favorite dish.

d. Token economy: a person with behavioural problem can be given a token as a reward every time a wanted
behaviour occurs. The token can be exchanged for a reward

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  Differential reinforcement:- to reduce unwanted behaviour- negative reinforcement for unwanted behaviour
and positive reinforcement for wanted behaviour.
 Other method is to provide positive reinforcement for wanted behaviour and ignores unwanted behaviour. Eg:
the wanted behaviour of politely asking to be taken for cinema is reinforced and the unwanted behaviour of
crying is ignored.

e. Systematic desensitization:- by Wolpe for treating phobias or anxiety

-Principle:- reciprocal inhibition

-Client is interviewed to elicit fear provoking situations
-therapist prepare a hierarchy of anxiety provoking stimuli from least to high.
-relaxes the client & ask the client to think about the least fearful situation.
- Client is asked to stop thinking of the fearful, situation if the slightest tension is felt
- -the client is able to imagine more severe fearful situations over sessions
 Reciprocal inhibition:-Presence of two mutually opposing forces at the same time , inhibits the weaker forces.
 Relaxation is first built and mild anxiety provoking scene is imagined , the anxiety is overcome by relaxation
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, thereby acting
as an antecedent factor in causing the faulty behaviour. The client may smoke to decrease anxiety, may
indulge in other activities such as eating, or be unable to concentrate for long hours on her/his study because
of the anxiety. Therefore, reduction of anxiety would decrease the unwanted behaviours of excessive eating or
smoking. Relaxation procedures are used 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 contract individual 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 asked to let go the tension. The
client is told that the tension is what the client has at present and that s/he has to get into the opposite state.
With repeated practice the client learns to relax all the muscles of the body.
f. Modelling:- client learns to behave in a certain way by observing the behaviour of a role model or the therapist
act as the role model. (Vicarious learning). Learning by observing others, is used and through a process of
rewarding small changes in the behaviour, the client is gradually acquire the behaviour of the model

2. Cognitive therapy
 Principle:- cause of the psychological disorders irrational thoughts and belief.
1. Rational emotive Therapy (RET) by Albert Ellis.
 First step is antecedent-belief-consequent analysis (ABC)

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 Antecedent-cause of the disorder.

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 Distorted/ irrational belief of the client is noted
 The irrational belief leads to the consequent (negative emotions and behaviours).
 Irrational beliefs are assessed through questionnaires and interviews.
 Irrational beliefs are refuted by the therapist through a process of non-directive questioning which help the
client to think deeper in to his or her problems and assumptions
 Gradually the client is able to change the irrational belief by making a change in his/ her philosophy about life.
 The ABC Model
 A. Something happens.(antecedent)
B. You have a belief about the situation.
C. You have an emotional reaction to the belief (consequent)
For example:
 A. Your employer falsely accuses you of taking money from her purse and threatens to fire you.
B. You believe, “She has no right to accuse me. She's a...........!”
C. You feel angry.
 If you had held a different belief, your emotional response would have been different:
 A. Your employer falsely accuses you of taking money from her purse and threatens to fire you.
B. You believe, “I must not lose my job. That would be unbearable.”
C. You feel anxious.
 it is not her accusation and threat that make you anxious; it is the belief that you must not lose your job, and
that losing your job would be unbearable.
 The goal of REBT is to help people change their irrational beliefs into rational beliefs. Changing beliefs is the
real work of therapy and is achieved by the therapist disputing the client's irrational beliefs. For example, the
therapist might ask, "Why must you win everyone's approval?" "Where is it written that other
people must treat you fairly?" "Just because you want something, why must you have it?" Disputing is the D of
the ABC model. When the client tries to answer the therapist's questions, s/he sees that there is no reason
why s/he absolutely must have approval, fair treatment, or anything else that s/he wants.
2. Cognitive therapy by Aaron beck.
 Child hood experiences provided by the family and society provide core schemas or systems which include
beliefs and action patterns.
 Eg:-a client who was neglected by the parents as a child develops the core schema. ‘ I am not wanted’ leading
to negative automatic thoughts.
 It is based on the premise that whenever we become upset, it is not the events taking place in our lives that
upset us; it is the beliefs that we hold that cause us to become depressed, anxious, enraged, etc

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  Negative thoughts are persistent irrational thoughts such as ‘nobody loves me’., ‘I am stupid’, I will not
succeed etc.
 This pattern of thoughts ( dysfunctional cognitive structures) lead to errors and assumptions about social
reality.
 Repeated occurrence of these thoughts lead to feeling of anxiety and depression.
 Therapist uses questioning, which is gentle , non threatening
 Eg:- why should every one love you., what does it mean to you to succeed.

 Gradually the client is able to change the irrational belief by making a change in his/ her philosophy about life.

 The question makes the client to think in a direction opposite to that of the negative thoughts where he gain
insight about his problem..
 The aim of the therapy is to achieve cognitive restructuring, which in turn reduces anxiety and depression
 Unlike psychodynamic therapy here the therapist shares his/ her method with the client.
 Lasting between 10- 20 sessions

3. Cognitive Behaviour Therapy ( CBT )

 For anxiety, depression, panic attack, personality disorders etc.
 It combines cognitive therapy and behavioural therapy.
 The rationale is that the psychological disorders are caused due to biological, psychological. and social reasons.
 A comprehensive technique.

4. Humanistic Existential Therapy

 Disorders are caused due to the feeling of loneliness, separation, and inability to find meaning to life.
 Human beings have a natural tendency for personal growth and self-actualization ( being a complete person)
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 understand the obstacle to self-actualization and is able to remove
them.
 Focusing on the client rather than the symptom.
 The therapy creates a permissive , non judgmental and accepting atmosphere in which the client’s emotion
can be expressed freely.
 Psychological problems (including substance abuse disorders) are viewed as the result of inhibited ability to
make , meaningful choices about how to live.
 Consequently, interventions are aimed at increasing client self-awareness and self-understanding.

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 Key words for humanistic therapy are acceptance and growth; the major themes of existential therapy are
client’s responsibility and freedom.
 Humanistic and existential approaches share a belief that people have the capacity for self-awareness and
choice.
 The humanistic perspective views human nature as basically good, with an inherent potential to maintain
healthy, meaningful relationships and to make choices that are in the interest of oneself and others.
 The therapist emphasizes growth and self-actualization rather than curing diseases or alleviating disorders.
 This perspective targets present conscious processes rather than unconscious processes and past causes.
 These therapies address factors leading to substance abuse disorders, such as lack of meaning in one's life, fear
of failure, loneliness
 The fundamental assumption is that the client has the freedom and responsibility to control his/ her own
behaviour.
 Therapist just acts as the facilitator and a guide and the client is responsible for the success of therapy.
 The chief aim of the therapy is to expand the clients awareness

a. Logo therapy :-by Victor Frankl -means treatment of soul.

 A Process of finding meaning to life- meaning –finding the spiritual truth of one’s existence
 Anxieties arise when problems of life are attached to the physical, psychological, or spiritual aspects of one’s
existence.
 Frankl emphasized 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 logo therapy is to help then patients to find meaning and responsibility in their life irrespective of
their life circumstances
b. Client centered therapy
 By Carl Roger.
 Therapy provides a warm relationship in which the client can solve his disintegrated feelings.
 Therapist show, empathy, unconditional positive regard, and non judgmental.
 This helps the client to feel secure and can trust the therapist and explore his/ her feeling.
 Therapy helps the client to understand his/her real self and meaning of existence.
c. Gestalt Therapy
 Gestalt means-’whole’
 Freiderick erl and Laura Perls.
 Goal:- increase individuals’ self-awareness and self-acceptance.

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 Therapy can also be used in group setting.

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 5. Alternative Therapies

 Alternative to conventional drug or psychotherapy.

 Yoga, meditation, acupuncture, herbal remedies.
 Yoga , & meditation gained much popularity in the past 25 years.
 Yoga is an ancient Indian technique
 Yoga refers to asanas (body posture) or pranayama (breathing practice) or both.
 Meditation refers to practice of focusing attention on breath or on an object or thought or manthra.
 Vipasana meditation (mindfulness) –here the person passively observe the various bodily sensations and
thought athat are passing through his / her mind.
 SKY ( Sudarshana Kriya Yoga):- rapid breathing technique-it is low risk, low cost technique for the treatment of
anxiety, PTSD , stress realted illness etc.
 Yoga technique enhances well being, mood, attention, reduce stress.
 Researches on SKY shows reduced level of depression.
 Kudalini Yoga:- researches in USA shows that it is effective for the treatment of OCD

Factors Contributing to Healing in Psychotherapy

 Techniques adopted by the therapist and its implementation with the patient/client.
 The therapeutic alliance formed between the therapist and the patient/client because of the regular availability
of the therapist, and the warmth and empathy provided by the therapist.
 Catharsis-process of emotional unburdening that occurs at the onset of the therapy.
 Non-specific factors that occur across different systems of psychotherapy and across different clients and
different therapist. Non-specific factors attributable to the client/patient are called patient variables and to the
therapist are called therapist variables
 Patient variables: motivation for change, expectation of improvement due to treatment, etc.
Therapist variables: positive nature, absence of unresolved emotional conflicts, presence of good mental health,
etc.

Ethics in Psychotherapy
 Informed Consent needs to be taken.
 Confidentiality of the client should be maintained.
 Alleviating personal distress and suffering should be the goal of all attempts of the therapist.
 Integrity of the practitioner-client relationship is important.
 Respect for human rights and dignity.
 Professional competence and skills are essential.

Rehabilitation Of the mentally ill

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 Treatment has two components: reduction of symptoms & improving the quality of life.
 Aim of the is to empower the patient to become a productive member of society
 In rehabilitation, patients are given occupational therapy, social skill training, vocational skills
 Cognitive retraining is given to improve the basic cognitive function of attention, memory.
 Vocational training is given to undertake productive employment.

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