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Chapter No. 5 Therapeutic Approaches And Counselling What is Psychotherapy? Psychotherapy is a voluntary relationship between the one seeking treatment or the client and the one who treats or the therapist. Purpose: To help the client to solve the psychological problems being faced by her or him. Aim: To change the maladaptive behaviours, decrease the sense of personal distress, and help the client to adapt better to his/her environment. The relationship is conducive for building the trust of the client so that problems may be freely discussed. Characteristics of Psychotherapies 1.There is systematic application of principles underlying the different theories of therapy.
- Only persons who have received practical training under expert supervision can practise psychotherapy.
- The situation involved a therapist and client who seeks and receives help for his/her emotional problems (this person is the focus of attention in the therapeutic process).
- The interaction of the therapist and the client results in the consolidation or formation of the therapeutic relationship. This is a confidential, interpersonal, and dynamic relationship. Goals of Psychotherapies: (i) Reinforcing client’s resolve for betterment. (ii) Lessening emotional pressure. (iii) Unfolding the potential for positive growth. (iv) Modifying habits. (v) Changing thinking patterns. (vi) Increasing self-awareness. (vii) Improving interpersonal relations and communication. (viii) Facilitating decision-making. (ix) Becoming aware of one’s choices in life. (x) 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. Two Components of Therapeutic Relationship
- Contractual Nature of the Relationship: Two willing individuals, the client and the therapist, enter into a partnership which aims at helping the client overcome his/ her problems. 2. Limited Duration of the Therapy: This alliance lasts until the client becomes able to deal with his/her problems and take control of his/her life.
Properties of Psychotherapies (i) It is a trusting and confiding relationship. (ii) 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. Classification of Psychotherapies
has acquired the operant response of smoking, which is maintained by the reinforcing value of relief from anxiety. ESTABLISHING OPERATION Antecedent Operation - Antecedent operations control behaviour by changing something that precedes such a behaviour. Consequent Operation - The change can be done by increasing or decreasing the reinforcing value of a particular consequence. Once the faulty behaviours which cause distress, have been identified, a treatment package is chosen. The aim of the treatment is to extinguish or eliminate the faulty behaviours and substitute them with adaptive behaviour patterns. The therapist does this through establishing antecedent operations and consequent operations. This is called establishing operation****. For example, if a child gives trouble in eating dinner, an establishing operation would be to decrease the quantity of food served at tea time. This would increase the hunger at dinner and thereby increase the reinforcing value of food at dinner. Praising the child when s/he eats properly tends to encourage this behaviour. The antecedent operation is the reduction of food at tea time and the consequent operation is praising the child for eating dinner. It establishes the response of eating dinner. 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, if necessary. Negative reinforcement and aversive conditioning are the two major techniques of behaviour modification. Negative reinforcement - refers to following an undesired response with an outcome that is painful or not liked. - For example, the teacher reprimands a child who shouts in class. This is negative reinforcement. Aversive conditioning refers to repeated association of undesired response with an aversive consequence. E.g An alcoholic is given a mild electric shock and asked to smell the alcohol. With repeated pairings the smell of alcohol is aversive as the pain of the shock is associated with it and the person will give up alcohol. 3. Positive reinforcement is given to increase the deficit if an adaptive behaviour occurs rarely, 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. 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. 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. Systematic Desensitization: A technique introduced by Wolpe for treating phobias or irrational fears. (i) The client is interviewed to elicit fear provoking situations. (ii) With the client, the therapist prepares a hierarchy of anxiety—provoking stimuli with the least anxiety-provoking stimuli at the bottom. (iii) The therapist relaxes the client and asks the client to think about the least anxiety- provoking situation. (iv) The client is asked to stop thinking of the situation if tension is felt. (v) Over sessions, the client is able to imagine more severe fear provoking situations while maintaining the relaxation. (vi) The client gets systematically desensitized to the fear. Operates on the principle of reciprocal inhibition —the presence of two mutually opposing forces (relaxation response vs. anxiety-provoking scene) at the same time, inhibits the weaker force. The client is able to tolerate progressively greater levels of anxiety because of his/her relaxed state. Modelling: 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 - learning by observing others, is used and through a process of rewarding small changes in the behaviour, the client gradually learns to acquire the behaviour of the model. BENEFIT OF BEHAVIOUR THERAPY Functioning behavior DURATION OF THE THERAPY Short 10-20 sessions
E.G 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. 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 characterised by cognitive distortions. Cognitive distortions are ways of thinking which are general in nature but which distort the reality in a negative manner. These p a t t e r ns o f t h o u g h t 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. METHOD OF TREATMENT The therapist uses questioning, which is gentle, non- threatening 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. These questions make the client think in a direction opposite to that of the negative automatic thoughts, which helps in gaining an insight of her/his dysfunctional schemas, and is able to alter her/his cognitive structures. Benefit of the Therapy o The aim of the therapy is to achieve this cognitive restructuring which, in turn, reduces anxiety and depression. Similar to behaviour therapy, cognitive therapy focuses on solving a specific problem of the client. Duration of the therapy It is short, lasting between 10 – 20 sessions.
COGNITIVE BEHAVIOUR THERAPY – CBT
The most popular therapy presently is the Cognitive Behaviour Therapy (CBT). CAUSE OF THE PROBLEM - The rationale is that the client’s distress has its origins in the biological, psychological, and social realms. CBT adopts a bio- psychosocial approach to the delineation of psychopathology. It combines cognitive therapy with behavioural techniques. Biological - addressing the biological aspects through relaxation procedures. Psychological - through behaviour therapy and cognitive therapy techniques. Social - through environmental manipulations. CBT a comprehensive technique which is easy to use, applicable to a variety of disorders, and has proven efficacy. 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. HUMANISTIC-EXISTENTIAL THERAPY Existential Therapy Client centered therapy Gestalt Therapy HUMANISTIC THERAPY CAUSE OF THE PROBLEM 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. What is Self- Actualization? 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, being in essence the same person in spite of the variety of experiences that one is subjected to. Just as lack of food or water causes distress, frustration of self-actualisation also causes distress. TREATMENT Healing occurs when the client is able to perceive the obstacles to self- actualisation in her/his life and is able to remove them. Self-actualisation requires free emotional expression. The family and society curb emotional expression, as it is feared that a free expression of emotions can har m society by unleashing destructive forces.
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 non- judgmental 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. This process of reflection helps the client to become integrated. Personal relationships improve with an increase in adjustment. In essence, this 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. Cause of the Problem Lack of Self Awareness and Acceptance is the reason for distress TREATMENT 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. This therapy can also be used in group settings. BENEFIT OF GESTALT THERAPY The goal of gestalt therapy is to increase an individual’s self-awareness and self- acceptance. E. BIOMEDICAL THERAPY Prescription of medicines is done by psychiatrists (qualified medical doctors who have specialized in the understanding, diagnosis and treatment of mental disorders). The nature of medicines used depends on the nature of the disorder: (i) Anti-psychotic drugs—severe mental disorders (schizophrenia, bipolar disorder). (ii) Milder drugs—common mental disorders (generalized anxiety, reactive depression). Cause side-effects which need to be understood and monitored—essential that medication is given under proper medical supervision. ELECTRO-CONVULSIVE THERAPY (ECT) (i) Mild electric shock given via electrodes to the brain of the patient to induce
convulsions. (ii) The shock is given by the psychiatrist only when necessary for the improvement of the patient. (iii) Not a routine treatment and is given only when drugs are not effective FACTORS CONTRIBUTING TO HEALING:
- Techniques adopted by the therapist and the implementation of the same with the client, e.g., CBT for an anxious client—relaxation procedures and cognitive restructuring contribute to the healing.
- 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.
- Catharsis: A process of emotional unburdening by a client when he/she is being interviewed in the initial sessions of therapy to understand the nature of the problem. 4. Non-specific Factors: These factors occur across different systems of psychotherapy and across different clients/patients and different therapists. (i) Patient Variables (motivation for change, expectation of improvement). (ii) Therapist Variables (positive nature, good mental health, absence of unresolved emotional conflicts). Ethics in Psychotherapy:
- Informed consent needs to be taken.
- Confidentiality of the client should be maintained.
- Alleviating personal distress 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. ALTERNATIVE THERAPIES - Yoga:
- An ancient Indian technique detailed in the Ashtanga Yoga of Patanjali’s Yoga Sutras.
- Refers to only the asanas (body posture component) or to pranayama (breathing practices).
- Techniques enhance well-being, mood, attention, mental focus, and stress tolerance.
- Reduces the time to go to sleep and improves the quality of sleep.
- Proper training by a skilled teacher and 30-minute practice everyday maximises the benefits. Meditation refers to the practice of focusing attention on breath or on an object or thought of a mantra. A. Sudarshana Kriya Yoga (SKY) (i) Rapid breathing techniques induce hyperventilation. (ii) Beneficial, low risk, low cost. (iii) Used as a public health intervention technique to alleviate PTSD in survivors of mass disasters. (iv) Reduces depression (research conducted at the National Institute of Mental Health and Neurosciences (NIMHANS).
the area of personality, vocational choice, etc.
- Electro Convulsive Therapy (ECT): Commonly called ‘shock treatment’. A biological treatment for unipolar depression in which electrodes attached to a patient’s head send an electric current through the brain, causing a convulsion. It is effective in the treatment of cases of several depression that fail to respond to drug therapy. - Empathy: Reacting to another’s feelings with an emotion response that is similar to the other’s feeling. - Free Association: A psychodynamic technique in which the patient describes verbally any thought, feeling or image that comes to mind, even if it seems unimportant. - Gestalt Therapy: An approach to therapy that attempts to integrate a client’s thoughts, feelings and behaviour into a unified whole. - Humanistic Therapy: A therapy in which the underlying assumption is that people have control over their behaviour, can make choices about their lives, and are essentially responsible for solving their own problems. - Modelling: A process of learning in which an individual acquires responses by observing and imitating others. - Psychodynamic Therapy: First suggested by Frend. Therapy based on the premise that the primary sources of abnormal behaviour are unresolved past conflicts and the possibility that unacceptable unconscious impulses will enter consciousness. - Psychotherapy: The use of any psychological technique in the treatment of mental/ psychological disorder or maladjustment. - Rational Emotive Therapy (RET): A therapeutic system developed by Albert Ellis. It seeks to replace irrational problem-provoking outlooks with more realistic ones. - Rehabilitation: Restoring an individual to normal or a satisfactory a state as possible, following an illness, criminal episode, etc. - Resistance: In psychoanalysis, attempts by the patient to block treatment. - Self-actualisation: A- state of self-fulfillment in which people realise their highest potential in their own unique way. - Systematic Desensitisation: A form of behavioural therapy in which phobic client learns to induce a relaxed state and then exposed to stimuli that elicit fear or phobia. - Therapeutic Alliance: The special relationship between the client and the therapist; contractual nature of the relationship and limited duration of the therapy are its two major components. - Transference: Strong positive or negative feelings toward the therapist on the part of individual undergoing psychoanalysis. - Unconditional Positive Regard: An attitude of acceptance and respect on the part of an observer, no matter what the other person says or does.
