sign in sign up
<<
Home , Behaviour therapy, Clinical formulation, Token economy

THERTHERTHERTHERAPEUTICAPEUTIC APPROACHESAPPROACHES

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

Nature and Process of Psychotherapy Therapeutic Relationship Type of Therapies Steps in the Formulation of a Client’s Problem (Box 5.1) Psychodynamic Relaxation Procedures (Box 5.2) Humanistic- Biomedical Therapy CONTENTS Alternative Therapies Rehabilitation of the Mentally Ill

Key Terms Summary Review Questions Project Ideas Weblinks Pedagogical Hints

89 Chapter 5 • Therapeutic Approaches

2021–22 In the preceding chapter, you have studied about major psychological disorders and the distress caused by them to the patient and others. In this chapter, you will learn about the various therapeutic methods that are used by psychotherapists to help their patients. There are various types of psychotherapy. Some of them focus on acquiring self-understanding; other therapies are more action-oriented. All approaches hinge on the basic issue of helping the patient overcome her/his debilitating condition. The effectiveness of a therapeutic approach for a patient depends on a number Introduction of factors such as severity of the disorder, degree of distress faced by others, and the availability of time, effort and money, among others. All therapeutic approaches are corrective and helping in nature. All of them involve an interpersonal relationship between the therapist and the client or patient. Some of them are directive in nature, such as psychodynamic, while some are non-directive such as person-centred. In this chapter, we will briefly discuss some of the major forms of psychotherapy.

everybody. An untrained person may NATURE AND PROCESS OF PSYCHOTHERAPY unintentionally cause more harm than any Psychotherapy is a voluntary relationship good, (iii) the therapeutic situation involves between the one seeking treatment or the a therapist and a client who seeks and client and the one who treats or the receives help for her/his emotional therapist. The purpose of the relationship problems (this person is the focus of is to help the client to solve the attention in the therapeutic process), and psychological problems being faced by her (iv) the interaction of these two persons — or him. The relationship is conducive for the therapist and the client — results in the consolidation/formation of the building the trust of the client so that therapeutic relationship. This is a problems may be freely discussed. confidential, interpersonal, and dynamic aim at changing the relationship. This human relationship is maladaptive behaviours, decreasing the central to any sort of psychological therapy sense of personal distress, and helping the and is the vehicle for change. client to adapt better to her/his All psychotherapies aim at a few or all environment. Inadequate marital, of the following goals : occupational and social adjustment also (i) Reinforcing client’s resolve for requires that major changes be made in an betterment. individual’s personal environment. (ii) Lessening emotional pressure. All psychotherapeutic approaches have (iii) Unfolding the potential for positive the following characteristics : (i) there is growth. systematic application of principles (iv) Modifying habits. underlying the different theories of (v) Changing thinking patterns. therapy, (ii) persons who have received (vi) Increasing self-awareness. practical training under expert supervision (vii) Improving interpersonal relations and can practice psychotherapy, and not communication.

90

2021–22 (viii)Facilitating decision-making. suffering of another but is not able to feel (ix) Becoming aware of one’s choices in like the other person. Intellectual life. understanding is cold in the sense that the (x) Relating to one’s social environment in person is unable to feel like the other a more creative and self-aware person and does not feel sympathy either. manner. On the other hand, empathy is present when one is able to understand the plight Therapeutic Relationship of another person, and feel like the other person. It means understanding things The special relationship between the client from the other person’s perspective, i.e. and the therapist is known as the putting oneself in the other person’s shoes. therapeutic relationship or alliance. It is Empathy enriches the therapeutic neither a passing acquaintance, nor a relationship and transforms it into a permanent and lasting relationship. There healing relationship. are two major components of a therapeutic The therapeutic alliance also requires alliance. The first component is the that the therapist must keep strict contractual nature of the relationship in confidentiality of the experiences, events, which two willing individuals, the client feelings or thoughts disclosed by the client. and the therapist, enter into a partnership The therapist must not exploit the trust which aims at helping the client overcome and the confidence of the client in anyway. her/his problems. The second component Finally, it is a professional relationship, of therapeutic alliance is the limited and must remain so. duration of the therapy. This alliance lasts until the client becomes able to deal with A classmate or friend of yours or your Activity her/his problems and take control of her/ favourite character in a TV serial may 5.1 his life. This relationship has several have recently experienced a negative unique properties. It is a trusting and or a traumatic life event (e.g., death confiding relationship. The high level of of a loved one, break-up of an trust enables the client to unburden important friendship or relationship) herself/himself to the therapist and confide of which you are aware. Try to put her/his psychological and personal yourself in the other person’s shoes, problems to the latter. The therapist try to experience how that person is feeling, what s/he is thinking and try encourages this by being accepting, to take her/his perspective of the empathic, genuine and warm to the client. entire situation. This will help you to The therapist conveys by her/his words understand better how that person is and behaviours that s/he is not judging feeling. the client and will continue to show the (Note : This exercise may be done in same positive feelings towards the client class, so that teachers can help even if the client is rude or confides all the students in overcoming any distress ‘wrong’ things that s/he may have done or experienced). thought about. This is the unconditional positive regard which the therapist has for the client. The therapist has empathy for TYPE OF THERAPIES the client. Empathy is different from sympathy and intellectual understanding Though all psychotherapies aim at of another person’s situation. In sympathy, removing human distress and fostering one has compassion and pity towards the effective behaviour, they differ greatly in

91 Chapter 5 • Therapeutic Approaches

2021–22 concepts, methods, and techniques. thoughts and feelings of the client. This Psychotherapies may be classified into material is interpreted to the client to three broad groups, viz. the help her/him to confront and resolve psychodynamic, behaviour, and existential the conflicts and thus overcome psychotherapies. In terms of the problems. Behaviour therapy identifies chronological order, psychodynamic the faulty conditioning patterns and therapy emerged first followed by sets up alternate behavioural behaviour therapy while the existential contingencies to improve behaviour. therapies which are also called the third The cognitive methods employed in this force, emerged last. The classification of type of therapy challenge the faulty psychotherapies is based on the following thinking patterns of the client to help parameters: her/him overcome psychological distress. The existential therapy 1. What is the cause, which has led to the provides a therapeutic environment problem? which is positive, accepting, and non- Psychodynamic therapy is of the view judgmental. The client is able to talk that intrapsychic conflicts, i.e. the about the problems and the therapist conflicts that are present within the acts as a facilitator. The client arrives psyche of the person, are the source of at the solutions through a process of psychological problems. According to personal growth. behaviour therapies, psychological problems arise due to faulty learning of 4. What is the nature of the therapeutic behaviours and cognitions. The relationship between the client and the existential therapies postulate that the therapist? questions about the meaning of one’s Psychodynamic therapy assumes that life and existence are the cause of the therapist understands the client’s psychological problems. intrapsychic conflicts better than the client and hence it is the therapist who 2. How did the cause come into existence? interprets the thoughts and feelings of In the psychodynamic therapy, the client to her/him so that s/he gains unfulfilled desires of childhood and an understanding of the same. The unresolved childhood fears lead to behaviour therapy assumes that the intrapsychic conflicts. The behaviour therapist is able to discern the faulty therapy postulates that faulty behaviour and thought patterns of the conditioning patterns, faulty learning, client. It further assumes that the and faulty thinking and beliefs lead to therapist is capable of finding out the maladaptive behaviours that, in turn, correct behaviour and thought lead to psychological problems. The patterns, which would be adaptive for existential therapy places importance the client. Both the psychodynamic and on the present. It is the current feelings the behaviour therapies assume that of loneliness, alienation, sense of futility the therapist is capable of arriving at of one’s existence, etc., which cause solutions to the client’s problems. In psychological problems. contrast to these therapies, the 3. What is the chief method of treatment? existential therapies emphasise that the Psychodynamic therapy uses the therapist merely provides a warm, methods of free and empathic relationship in which the reporting of dreams to elicit the client feels secure to explore the nature

92 Psychology

2021–22 and causes of her/his problems by and one’s aspirations, emotions and herself/himself. motives. 5. What is the chief benefit to the client? 6. What is the duration of treatment? Psychodynamic therapy values The duration of classical psycho- emotional insight as the important analysis may continue for several years. benefit that the client derives from the However, several recent versions of treatment. Emotional insight is present psychodynamic therapies are completed when the client understands her/his in 10–15 sessions. Behaviour and conflicts intellectually; is able to accept cognitive behaviour therapies as well as the same emotionally; and is able to existential therapies are shorter and are change her/his emotions towards the completed in a few months. conflicts. The client’s symptoms and Thus, different types of psycho- distresses reduce as a consequence of therapies differ on multiple parameters. this emotional insight. The behaviour However, they all share the common therapy considers changing faulty method of providing treatment for behaviour and thought patterns to psychological distress through psycho- adaptive ones as the chief benefit of the logical means. The therapist, the treatment. Instituting adaptive or therapeutic relationship, and the process healthy behaviour and thought of therapy become the agents of change in patterns ensures reduction of distress the client leading to the alleviation of and removal of symptoms. The psychological distress. The process of humanistic therapy values personal psychotherapy begins by formulating the growth as the chief benefit. Personal client’s problem. Steps involved in the growth is the process of gaining formulation of a client’s problem are given increasing understanding of oneself, in Box 5.1.

Steps in the Formulation of a Client’s Problem Box 5.1 refers to formulating the problem of the client in the therapeutic model being used for the treatment. The clinical formulation has the following advantages: 1. Understanding of the problem : The therapist is able to understand the full implications of the distress being experienced by the client. 2. Identification of the areas to be targetted for treatment in psychotherapy : The theoretical formulation clearly identifies the problem areas to be targetted for therapy. Thus, if a client seeks help for inability to hold a job and reports inability to face superiors, the clinical formulation in behaviour therapy would state it as lack of skills and anxiety. The target areas have thus been identified as inability to assert oneself and heightened anxiety. 3. Choice of techniques for treatment : The choice of techniques for treatment depends on the therapeutic system in which the therapist has been trained. However, even within this broad domain, the choice of techniques, timing of the techniques, and expectations of outcome of the therapy depend upon the clinical formulation. The clinical formulation is an ongoing process. Formulations may require reformulations as clinical insights are gained in the process of therapy. Usually the first one or two sessions yield enough clinical material for the initial clinical formulation. It is not advisable to start psychotherapy without a clinical formulation.

93 Chapter 5 • Therapeutic Approaches

2021–22 a therapeutic relationship is established, Activity Gather information about some 5.2 and the client feels comfortable, the institutions you know which offer therapist makes her/him lie down on the psychiatric/psychotherapeutic help. couch, close her/his eyes and asks her/ him to speak whatever comes to mind without censoring it in anyway. The client The following sections explain is encouraged to freely associate one representative therapies from each of the thought with another, and this method is three major systems of psychotherapy called the method of free association. The mentioned earlier. censoring superego and the watchful ego are kept in abeyance as the client speaks Psychodynamic Therapy whatever comes to mind in an atmosphere As you have already read, the that is relaxed and trusting. As the psychodynamic therapy pioneered by therapist does not interrupt, the free flow is the oldest form of of ideas, desires and conflicts of the psychotherapy. His close collaborator Carl unconscious, which had been suppressed Jung modified it to what came to be known by the ego, emerge into the conscious as the analytical psychotherapy. mind. This free uncensored verbal Subsequently, Freud’s successors, known narrative of the client is a window into the as Neo-Freudians, established their own client’s unconscious to which the therapist versions of classical psychodynamic gains access. Along with this technique, therapy. Broadly, the psychodynamic the client is asked to write down her/his therapy has conceptualised the structure dreams upon waking up. Psychoanalysts of the psyche, dynamics between different look upon dreams as symbols of the components of the psyche, and the source unfulfilled desires present in the of psychological distress. You have already unconscious. The images of the dreams are studied these concepts in the chapters on symbols which signify intrapsychic forces. Self and Personality, and Psychological Dreams use symbols because they are Disorders. The method of treatment, steps indirect expressions and hence would not in the treatment, nature of the therapeutic alert the ego. If the unfulfilled desires are relationship, and the expected outcome expressed directly, the ever-vigilant ego from the psychodynamic therapy are would suppress them and that would lead explained below. to anxiety. These symbols are interpreted according to an accepted convention of Methods of Eliciting the Nature of translation as the indicators of unfulfilled Intrapsychic Conflict desires and conflicts. Since the psychoanalytic approach views Modality of Treatment intrapsychic conflicts to be the cause of psychological disorder, the first step in the and Interpretation are the treatment is to elicit this intrapsychic means of treating the patient. As the conflict. has invented free unconscious forces are brought into the association and dream interpretation as conscious realm through free association two important methods for eliciting the and dream interpretation described above, intrapsychic conflicts. The free association the client starts identifying the therapist method is the main method for with the authority figures of the past, understanding the client’s problems. Once usually childhood. The therapist may be

94 Psychology

2021–22 seen as the punitive father, or as the anxiety, fear, or shame, which are causing negligent mother. The therapist maintains the resistance. a non-judgmental yet permissive attitude Interpretation is the fundamental and allows the client to continue with this mechanism by which change is effected. process of emotional identification. This is Confrontation and clarification are the the process of transference. The therapist two analytical techniques of interpretation. encourages this process because it In confrontation, the therapist points out helps her/him in understanding the to the client an aspect of her/his psyche unconscious conflicts of the client. The that must be faced by the client. client acts out her/his frustrations, anger, Clarification is the process by which the fear, and depression that s/he harboured therapist brings a vague or confusing event towards that person in the past, but could into sharp focus. This is done by not express at that time. The therapist separating and highlighting important becomes a substitute for that person in details about the event from unimportant the present. This stage is called ones. Interpretation is a more subtle transference neurosis. A full-blown process. It is considered to be the pinnacle transference neurosis is helpful in making of psychoanalysis. The therapist uses the the therapist aware of the nature of unconscious material that has been intrapsychic conflicts suffered by the uncovered in the process of free client. There is the positive transference association, dream interpretation, in which the client idolises, or falls in transference and resistance to make the love with the therapist, and seeks client aware of the psychic contents and the therapist’s approval. Negative conflicts which have led to the occurrence transference is present when the client of certain events, symptoms and conflicts. has feelings of hostility, anger, and Interpretation can focus on intrapsychic resentment towards the therapist. conflicts or on deprivations suffered in The process of transference is met with childhood. The repeated process of using resistance. Since the process of confrontation, clarification, and inter- transference exposes the unconscious pretation is known as working through. wishes and conflicts, thereby increasing Working through helps the patient to the distress levels, the client resists understand herself/himself and the source transference. Due to resistance, the client of the problem and to integrate the opposes the progress of therapy in order uncovered material into her/his ego. to protect herself/himself from the recall The outcome of working through is of painful unconscious memories. insight. Insight is not a sudden event but Resistance can be conscious or a gradual process wherein the unconscious unconscious. Conscious resistance is memories are repeatedly integrated into present when the client deliberately hides conscious awareness; these unconscious some information. Unconscious resistance events and memories are re-experienced in is assumed to be present when the client transference and are worked through. As becomes silent during the therapy session, this process continues, the client starts to recalls trivial details without recalling the understand herself/himself better at an emotional ones, misses appointments, and intellectual and emotional level, and gains comes late for therapy sessions. The insight into her/his conflicts and therapist overcomes the resistance by problems. The intellectual understanding repeatedly confronting the patient about it is the intellectual insight. The emotional and by uncovering emotions such as understanding, acceptance of one’s

95 Chapter 5 • Therapeutic Approaches

2021–22 irrational reaction to the unpleasant events faulty patterns are corrected in the of the past, and the willingness to change present. emotionally as well as making the change The clinical application of learning is emotional insight. Insight is the end theory principles constitute behaviour point of therapy as the client has gained therapy. Behaviour therapy consists of a a new understanding of herself/himself. In large set of specific techniques and turn, the conflicts of the past, defence interventions. It is not a unified theory, mechanisms and physical symptoms are which is applied irrespective of the clinical no longer present and the client becomes diagnosis or the symptoms present. The a psychologically healthy person. symptoms of the client and the clinical Psychoanalysis is terminated at this diagnosis are the guiding factors in the stage. selection of the specific techniques or interventions to be applied. Treatment of Duration of Treatment phobias or excessive and crippling fears Psychoanalysis lasts for several years, with would require the use of one set of one hour session for 4–5 days per week. techniques while that of anger outbursts It is an intense treatment. There are three would require another. A depressed client stages in the treatment. Stage one is the would be treated differently from a client initial phase. The client becomes familiar who is anxious. The foundation of with the routines, establishes a therapeutic behaviour therapy is on formulating relationship with the analyst, and gets dysfunctional or faulty behaviours, the some relief with the process of recollecting factors which reinforce and maintain these the superficial materials from the behaviours, and devising methods by consciousness about the past and present which they can be changed. troublesome events. Stage two is the Method of Treatment middle phase, which is a long process. It is characterised by transference, resistance The client with psychological distress or on the part of the client, and confrontation with physical symptoms, which cannot be and clarification, i.e. working through on attributed to physical disease, is the therapist’s part. All these processes interviewed with a view to analyse her/his finally lead to insight. The third phase is behaviour patterns. Behavioural analysis is the termination phase wherein the conducted to find malfunctioning relationship with the analyst is dissolved behaviours, the antecedents of faulty and the client prepares to leave the learning, and the factors that maintain therapy. or continue faulty learning. Malfunctioning behaviours are those behaviours which Behaviour Therapy cause distress to the client. Antecedent Behaviour therapies postulate that factors are those causes which predispose psychological distress arises because of the person to indulge in that behaviour. faulty behaviour patterns or thought Maintaining factors are those factors which patterns. It is, therefore, focused on the lead to the persistence of the faulty behaviour and thoughts of the client in the behaviour. An example would be a young present. The past is relevant only to the person who has acquired the extent of understanding the origins of the malfunctioning behaviour of smoking and faulty behaviour and thought patterns. The seeks help to get rid of smoking. past is not activated or relived. Only the Behavioural analysis conducted by

96 Psychology

2021–22 interviewing the client and the family food at dinner. Praising the child when members reveals that the person started s/he eats properly tends to encourage this smoking when he was preparing for the behaviour. The antecedent operation is the annual examination. He had reported relief reduction of food at tea time and the from anxiety upon smoking. Thus, anxiety- consequent operation is praising the child provoking situation becomes the causative for eating dinner. It establishes the or antecedent factor. The feeling of relief response of eating dinner. becomes the maintaining factor for him to Behavioural Techniques continue smoking. The client has acquired the operant response of smoking, which is A range of techniques is available for maintained by the reinforcing value of relief changing behaviour. The principles of these from anxiety. techniques are to reduce the arousal level Once the faulty behaviours which of the client, alter behaviour through cause distress, have been identified, a or operant treatment package is chosen. The aim of conditioning with different contingencies of the treatment is to extinguish or eliminate , as well as to use vicarious the faulty behaviours and substitute them learning procedures, if necessary. with adaptive behaviour patterns. The Negative and aversive therapist does this through establishing conditioning are the two major techniques antecedent operations and consequent of behaviour modification. As you have operations. Antecedent operations control already studied in Class XI, responses that behaviour by changing something that lead organisms to get rid of painful stimuli precedes such a behaviour. The change or avoid and escape from them provide can be done by increasing or decreasing negative reinforcement. For example, one the reinforcing value of a particular learns to put on woollen clothes, burn consequence. This is called establishing firewood or use electric heaters to avoid the operation. For example, if a child gives unpleasant cold weather. One learns to trouble in eating dinner, an establishing move away from dangerous stimuli because operation would be to decrease the they provide negative reinforcement. quantity of food served at tea time. This Aversive conditioning refers to repeated would increase the hunger at dinner and association of undesired response with an thereby increase the reinforcing value of aversive consequence. For example, an

Relaxation Procedures Box 5.2 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. You will learn about meditation at a later point in this chapter.

97 Chapter 5 • Therapeutic Approaches

2021–22 alcoholic is given a mild electric shock and fears. The client is interviewed to elicit fear- asked to smell the alcohol. With repeated provoking situations and together with the pairings the smell of alcohol is aversive as client, the therapist prepares a hierarchy the pain of the shock is associated with it of anxiety-provoking stimuli with the least and the person will give up alcohol. If an anxiety-provoking stimuli at the bottom of adaptive behaviour occurs rarely, positive the hierarchy. The therapist relaxes the reinforcement is given to increase the client and asks the client to think about deficit. For example, if a child does not do the least anxiety-provoking situation. homework regularly, positive reinforcement Box 5.2 gives details of relaxation may be used by the child’s mother by procedures. The client is asked to stop preparing the child’s favourite dish thinking of the fearful situation if the whenever s/he does homework at the slightest tension is felt. Over sessions, the appointed time. The positive reinforcement client is able to imagine more severe fear- of food will increase the behaviour of doing provoking situations while maintaining the homework at the appointed time. Persons relaxation. The client gets systematically with behavioural problems can be given a desensitised to the fear. token as a reward every time a wanted The principle of reciprocal inhibition behaviour occurs. The tokens are collected operates here. This principle states that the and exchanged for a reward such as an presence of two mutually opposing forces outing for the patient or a treat for the child. at the same time, inhibits the weaker force. This is known as . Thus, the relaxation response is first built Unwanted behaviour can be reduced up and mildly anxiety-provoking scene is and wanted behaviour can be increased imagined, and the anxiety is overcome by simultaneously through differential the relaxation. The client is able to tolerate reinforcement. Positive reinforcement for progressively greater levels of anxiety the wanted behaviour and negative because of her/his relaxed state. reinforcement for the unwanted behaviour Modelling is the procedure wherein the attempted together may be one such client learns to behave in a certain way by method. The other method is to positively observing the behaviour of a role model or reinforce the wanted behaviour and ignore the therapist who initially acts as the role the unwanted behaviour. The latter method model. Vicarious learning, i.e. learning by is less painful and equally effective. For observing others, is used and through a example, let us consider the case of a girl who sulks and cries when she is not taken to the cinema when she asks. The parent Your friend is feeling very nervous Activity 5.3 is instructed to take her to the cinema if and panicky before the examinations. she does not cry and sulk but not to take S/he is pacing up and down, is unable to study and feels s/he has her if she does. Further, the parent is forgotten all that s/he has learnt. Try instructed to ignore the girl when she cries to help her/him to relax by inhaling and sulks. The wanted behaviour of (taking in a deep breath), holding it politely asking to be taken to the cinema for sometime (5–10 seconds), then increases and the unwanted behaviour of exhaling (releasing the breath). Ask crying and sulking decreases. her/him to repeat this 5–10 times. Also ask her/him to remain focused You read about phobias or irrational on her/his breathing. You can do fears in the previous chapter. Systematic the same exercise when you feel desensitisation is a technique introduced nervous. by Wolpe for treating phobias or irrational

98 Psychology

2021–22 process of rewarding small changes in the assumptions about life and problems. behaviour, the client gradually learns to Gradually the client is able to change the acquire the behaviour of the model. irrational beliefs by making a change in There is a great variety of techniques in her/his philosophy about life. The rational behaviour therapy. The skill of the belief system replaces the irrational belief therapist lies in conducting an accurate system and there is a reduction in behavioural analysis and building a psychological distress. treatment package with the appropriate Another cognitive therapy is that of techniques. Aaron Beck. His theory of psychological distress characterised by anxiety or Cognitive Therapy depression, states that childhood experiences provided by the family and Cognitive therapies locate the cause of society develop core schemas or systems, psychological distress in irrational which include beliefs and action patterns thoughts and beliefs. in the individual. Thus, a client, who was formulated the Rational Emotive Therapy neglected by the parents as a child, (RET). The central thesis of this therapy is develops the core schema of “I am not that irrational beliefs mediate between the wanted”. During the course of life, a critical antecedent events and their consequences. incident occurs in her/his life. S/he is The first step in RET is the antecedent- publicly ridiculed by the teacher in school. belief-consequence (ABC) analysis. This critical incident triggers the core Antecedent events, which caused the schema of “I am not wanted” leading to the psychological distress, are noted. The development of negative automatic client is also interviewed to find the thoughts. Negative thoughts are persistent irrational beliefs, which are distorting the irrational thoughts such as “nobody loves present reality. Irrational beliefs may not me”, “I am ugly”, “I am stupid”, “I will not be supported by empirical evidence in the succeed”, etc. Such negative automatic environment. These beliefs are thoughts are characterised by cognitive characterised by thoughts with ‘musts’ distortions. Cognitive distortions are ways and ‘shoulds’, i.e. things ‘must’ and of thinking which are general in nature but ‘should’ be in a particular manner. which distort the reality in a negative Examples of irrational beliefs are, “One manner. These patterns of thought should be loved by everybody all the time”, are called dysfunctional cognitive “Human misery is caused by external structures. They lead to errors of cognition events over which one does not have any about the social reality. control”, etc. This distorted perception of Repeated occurrence of these thoughts the antecedent event due to the irrational leads to the development of feelings of belief leads to the consequence, i.e. anxiety and depression. The therapist uses negative emotions and behaviours. questioning, which is gentle, non- Irrational beliefs are assessed through threatening disputation of the client’s questionnaires and interviews. In the beliefs and thoughts. Examples of such process of RET, the irrational beliefs are question would be, “Why should everyone refuted by the therapist through a process love you?”, “What does it mean to you to of non-directive questioning. The nature of succeed?”, etc. The questions make the questioning is gentle, without probing or client think in a direction opposite to that being directive. The questions make the of the negative automatic thoughts client to think deeper into her/his whereby s/he gains insight into the nature

99 Chapter 5 • Therapeutic Approaches

2021–22 of her/his dysfunctional schemas, and is and self-actualisation, and an innate need able to alter her/his cognitive structures. to grow emotionally. When these needs are The aim of the therapy is to achieve this curbed by society and family, human which, in turn, beings experience psychological distress. reduces anxiety and depression. Self-actualisation is defined as an innate Similar to behaviour therapy, cognitive or inborn force that moves the person to therapy focuses on solving a specific become more complex, balanced, and problem of the client. Unlike psycho- integrated, i.e. achieving the complexity dynamic therapy, behaviour therapy is and balance without being fragmented. open, i.e. the therapist shares her/his Integrated means a sense of whole, being method with the client. It is short, lasting a complete person, being in essence the between 10–20 sessions. same person in spite of the variety of experiences that one is subjected to. Just Cognitive Behaviour Therapy as lack of food or water causes distress, frustration of self-actualisation also causes The most popular therapy presently is the distress. Cognitive Behaviour Therapy (CBT). Healing occurs when the client is able Research into the outcome and to perceive the obstacles to self- effectiveness of psychotherapy has actualisation in her/his life and is able to conclusively established CBT to be a short remove them. Self-actualisation requires and efficacious treatment for a wide range free emotional expression. The family and of psychological disorders such as anxiety, society curb emotional expression, as it is depression, panic attacks, and borderline feared that a free expression of emotions personality, etc. CBT adopts a bio- can harm society by unleashing psychosocial approach to the delineation of destructive forces. This curb leads to psychopathology. It combines cognitive destructive behaviour and negative therapy with behavioural techniques. emotions by thwarting the process of The rationale is that the client’s distress emotional integration. Therefore, the has its origins in the biological, therapy creates a permissive, non- psychological, and social realms. Hence, judgmental and accepting atmosphere in addressing the biological aspects through which the client’s emotions can be freely relaxation procedures, the psychological expressed and the complexity, balance and ones through behaviour therapy and integration could be achieved. The cognitive therapy techniques and the social fundamental assumption is that the client ones with environmental manipulations has the freedom and responsibility to makes CBT a comprehensive technique control her/his own behaviour. The which is easy to use, applicable to a variety therapist is merely a facilitator and guide. of disorders, and has proven efficacy. It is the client who is responsible for the success of therapy. The chief aim of the Humanistic-existential Therapy therapy is to expand the client’s awareness. The humanistic-existential therapies Healing takes place by a process of postulate that psychological distress arises understanding the unique personal from feelings of loneliness, alienation, and experience of the client by herself/himself. an inability to find meaning and genuine The client initiates the process of self- fulfilment in life. Human beings are growth through which healing takes motivated by the desire for personal growth place.

100 Psychology

2021–22 Existential Therapy relationship in which the client can reconnect with her/his disintegrated Victor Frankl, a psychiatrist and feelings. The therapist shows empathy, i.e. neurologist propounded the . understanding the client’s experience as if Logos is the Greek word for soul and it were her/his own, is warm and has Logotherapy means treatment for the soul. unconditional positive regard, i.e. total Frankl calls this process of finding acceptance of the client as s/he is. meaning even in life-threatening Empathy sets up an emotional resonance circumstances as the process of meaning between the therapist and the client. making. The basis of meaning making is a Unconditional positive regard indicates person’s quest for finding the spiritual that the positive warmth of the therapist truth of one’s existence. Just as there is is not dependent on what the client reveals an unconscious, which is the repository of or does in the therapy sessions. This instincts (see Chapter 2), there is a unique unconditional warmth ensures that spiritual unconscious, which is the the client feels secure and can trust the storehouse of love, aesthetic awareness, therapist. The client feels secure enough to and values of life. Neurotic anxieties arise explore her/his feelings. The therapist when the problems of life are attached to reflects the feelings of the client in a non- the physical, psychological or spiritual judgmental manner. The reflection is aspects of one’s existence. Frankl achieved by rephrasing the statements of emphasised the role of spiritual anxieties the client, i.e. seeking simple clarifications in leading to meaninglessness and hence to enhance the meaning of the client’s it may be called an existential anxiety, i.e. statements. This process of reflection helps neurotic anxiety of spiritual origin. The the client to become integrated. Personal goal of logotherapy is to help the patients relationships improve with an increase in to find meaning and responsibility in adjustment. In essence, this therapy helps their life irrespective of their life a client to become her/his real self with the circumstances. The therapist emphasises therapist working as a facilitator. the unique nature of the patient’s life and encourages them to find meaning in their life. In Logotherapy, the therapist is open The German word gestalt means ‘whole’. and shares her/his feelings, values and This therapy was given by Freiderick (Fritz) his/her own existence with the client. The Perls together with his wife Laura Perls. emphasis is on here and now. Transference The goal of gestalt therapy is to increase is actively discouraged. The therapist an individual’s self-awareness and self- reminds the client about the immediacy of acceptance. The client is taught to the present. The goal is to facilitate the recognise the bodily processes and the client to find the meaning of her/his being. emotions that are being blocked out from awareness. The therapist does this by Client-centred Therapy encouraging the client to act out fantasies about feelings and conflicts. This therapy Client-centred therapy was given by Carl can also be used in group settings. Rogers. Rogers combined scientific rigour with the individualised practice of client- Biomedical Therapy centred psychotherapy. Rogers brought into psychotherapy the concept of self, with Medicines may be prescribed to treat freedom and choice as the core of one’s psychological disorders. Prescription of being. The therapy provides a warm medicines for treatment of mental

101 Chapter 5 • Therapeutic Approaches

2021–22 disorders is done by qualified medical and the implementation of the same professionals known as psychiatrists. They with the patient/client. If the are medical doctors who have specialised behavioural system and the CBT school in the understanding, diagnosis and are adopted to heal an anxious client, treatment of mental disorders. The nature the relaxation procedures and the of medicines used depends on the nature cognitive restructuring largely of the disorders. Severe mental disorders contribute to the healing. such as or bipolar disorder 2. The therapeutic alliance, which is require anti-psychotic drugs. Common formed between the therapist and the mental disorders such as generalised patient/client, has healing properties, anxiety or reactive depression may also because of the regular availability of the require milder drugs. The medicines therapist, and the warmth and prescribed to treat mental disorders can empathy provided by the therapist. cause side-effects which need to be 3. At the outset of therapy while the understood and monitored. Hence, it is patient/client is being interviewed in essential that medication is given under the initial sessions to understand the proper medical supervision. Even the nature of the problem, s/he unburdens drugs which normal individuals use to stay the emotional problems being faced. awake to study for examinations or to get This process of emotional unburdening a ‘high’ at a party have dangerous is known as , and it has side-effects. These drugs can cause healing properties. , and harm the brain and the 4. There are several non-specific factors body. Therefore, it is dangerous to self- associated with psychotherapy. Some medicate with drugs which affect the mind. of these factors are attributed to the You must have seen people with mental patient/client and some to the problems being given electric shocks in therapist. These factors are called films. Electro-convulsive Therapy (ECT) non-specific because they occur across is another form of biomedical therapy. Mild different systems of psychotherapy and electric shock is given via electrodes to the across different clients/patients and brain of the patient to induce convulsions. different therapists. Non-specific factors The shock is given by the psychiatrist only attributable to the client/patient are when it is necessary for the improvement for change, expectation of of the patient. ECT is not a routine improvement due to the treatment, etc. treatment and is given only when drugs are These are called patient variables. not effective in controlling the symptoms Non-specific factors attributable to the of the patient. therapist are positive nature, absence of unresolved emotional conflicts, Factors Contributing to Healing in presence of good , Psychotherapy etc. These are called therapist As we have read, psychotherapy is a variables. treatment of psychological distress. There Ethics in Psychotherapy are several factors which contribute to the healing process. Some of these factors are Some of the ethical standards that need to as follows : be practiced by professional psycho- 1. A major factor in the healing is the therapists are : techniques adopted by the therapist 1. Informed consent needs to be taken.

102 Psychology

2021–22 2. Confidentiality of the client should be SKY has been used as a public health maintained. intervention technique to alleviate PTSD in 3. Alleviating personal distress and survivors of mass disasters. Yoga suffering should be the goal of all techniques enhance well-being, mood, attempts of the therapist. attention, mental focus, and stress 4. Integrity of the practitioner-client tolerance. Proper training by a skilled relationship is important. teacher and a 30-minute practice every day 5. Respect for human rights and dignity. will maximise the benefits. Research 6. Professional competence and skills are conducted at the National Institute of essential. Mental Health and Neurosciences (NIMHANS), India, has shown that SKY Alternative Therapies reduces depression. Further, alcoholic patients who practice SKY have reduced Alternative therapies are so called, because depression and stress levels. Insomnia is they are alternative treatment possibilities treated with yoga. Yoga reduces the time to the conventional drug treatment or to go to sleep and improves the quality of psychotherapy. There are many alternative sleep. therapies such as yoga, meditation, Kundalini Yoga taught in the USA has acupuncture, herbal remedies and so on. been found to be effective in treatment of In the past 25 years, yoga and meditation mental disorders. The Institute for Non- have gained popularity as treatment linear Science, University of California, San programmes for psychological distress. Diego, USA has found that Kundalini Yoga Yoga is an ancient Indian technique is effective in the treatment of obsessive- detailed in the Ashtanga Yoga of Patanjali’s compulsive disorder. Kundalini Yoga Yoga Sutras. Yoga as it is commonly called combines pranayama or breathing today either refers to only the asanas or techniques with chanting of mantras. body posture component or to breathing Prevention of repeated episodes of practices or pranayama, or to a depression may be helped by mindfulness- combination of the two. Meditation refers based meditation or Vipasana. This to the practice of attention on meditation would help the patients to breath or on an object or thought or a process emotional stimuli better and hence mantra. Here attention is focused. In prevent biases in the processing of these Vipasana meditation, also known as stimuli. mindfulness-based meditation, there is no fixed object or thought to hold the REHABILITATION OF THE MENTALLY ILL attention. The person passively observes the various bodily sensations and thoughts The treatment of psychological disorders that are passing through in her or his has two components, i.e. reduction of awareness. symptoms, and improving the level of The rapid breathing techniques to functioning or quality of life. In the case induce hyperventilation as in Sudarshana of milder disorders such as generalised Kriya Yoga (SKY) is found to be a anxiety, reactive depression or phobia, beneficial, low-risk, low-cost adjunct to the reduction of symptoms is associated with treatment of stress, anxiety, post-traumatic an improvement in the quality of life. stress disorder (PTSD), depression, stress- However, in the case of severe mental related medical illnesses, , disorders such as schizophrenia, reduction and rehabilitation of criminal offenders. of symptoms may not be associated with

103 Chapter 5 • Therapeutic Approaches

2021–22 an improvement in the quality of life. Many making, paper bag making and weaving to patients suffer from negative symptoms help them to form a work discipline. Social such as disinterest and lack of motivation skills training helps the patients to develop to do work or to interact with people. interpersonal skills through role play, Rehabilitation is required to help such imitation and instruction. The objective is patients become self-sufficient. The aim of to teach the patient to function in a social rehabilitation is to empower the patient to group. Cognitive retraining is given to become a productive member of society to improve the basic cognitive functions of the extent possible. In rehabilitation, the attention, memory and executive functions. patients are given occupational therapy, After the patient improves sufficiently, social skills training, and vocational vocational training is given wherein the therapy. In occupational therapy, the patient is helped to gain skills necessary patients are taught skills such as candle to undertake productive employment.

Key Terms Alternative therapy, Behaviour therapy, Biomedical therapy, Client-centred therapy, Cognitive behaviour therapy, Empathy, Gestalt therapy, Humanistic therapy, Psycho dynamic therapy, Psychotherapy, Rehabilitation, Resistance, Self-actualisation, Therapeutic alliance, Transference, Unconditional positive regard.

• Psychotherapy is a treatment for the healing of psychological distress. It is not a homogenous treatment method. There are about 400 different types of psychotherapy. • Psychoanalysis, behavioural, cognitive and humanistic-existential are the important systems of psychotherapy. There are many schools within each of the above systems. • The important components of psychotherapy are the clinical formulation, i.e. statement of the client’s problem and treatment in the framework of a particular therapy. • Therapeutic alliance is the relation between the therapist and the client in which the client has trust in the therapist and the therapist has empathy for the client. • The predominant mode of psychotherapy for adults with psychological distress is individual psychotherapy. The therapist requires to be professionally trained before embarking on the journey of psychotherapy. • Alternative therapies such as some yogic and meditative practices have been found to be effective in treating certain psychological disorders. • Rehabilitation of the mentally ill is necessary to improve their quality of life once their active symptoms are reduced.

Review Questions 1. Describe the nature and scope of psychotherapy. Highlight the importance of therapeutic relationship in psychotherapy. 2. What are the different types of psychotherapy? On what basis are they classified? 3. A therapist asks the client to reveal all her/his thoughts including early childhood experiences. Describe the technique and type of therapy being used. 4. Discuss the various techniques used in behaviour therapy. 5. Explain with the help of an example how cognitive distortions take place. 6. Which therapy encourages the client to seek personal growth and actualise their potential? Write about the therapies which are based on this principle.

104 Psychology

2021–22 7. What are the factors that contribute to healing in psychotherapy? Enumerate some of the alternative therapies. 8. What are the techniques used in the rehabilitation of the mentally ill? 9. How would a social learning theorist account for a phobic fear of lizards/cockroaches? How would a psychoanalyst account for the same phobia? 10. Should Electro-convulsive Therapy (ECT) be used in the treatment of mental disorders? 11. What kind of problems is cognitive behaviour therapy best suited for?

Project 1. In school at times you get good points (or gold points or stars) when you do well and Ideas bad or black points when you do something wrong. This is an example of a token system. With the help of your classmates make a list of all those school and classroom activities for which you are rewarded or receive praise from your teacher or appreciation from your friends. Also make a list of all those activities for which your teacher scolds you or your classmates get angry with you. 2. Describe a person in your past or present who has consistently demonstrated unconditional positive regard towards you. What effect, if any, did (or does) this have on you? Explain. Gather the same information from more friends and prepare a report.

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

Pedagogical Hints 1. Students could be asked to connect the different therapeutic approaches to some of the theories of personality they have studied in Chapter 2 on Self and Personality. 2. Role-play and dramatisation of certain student-related behavioural issues, such as break-up of relationship with a friend would evoke interest among the students and also emphasise the application of psychology. 3. As therapy is a highly skilled process requiring professional training, students should be refrained from treating it in a frivolous manner. 4. Any activity/discussion, which may have a serious impact on the psyche of the students, should be properly transacted in the presence of the teacher.

105 Chapter 5 • Therapeutic Approaches

2021–22