5. THERAPEUTIC APPROACHES
After reading this chapter, you would be able to:
familiarise yourself with the basic nature and process of psychotherapy, appreciate that there are different types of therapies 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)
- Behaviour Therapy
- Relaxation Procedures (Box 5.2)
- Cognitive Therapy
- Humanistic-existential Therapy
- Alternative Therapies
- Rehabilitation of the Mentally Ill
Key Terms Summary Review Questions Project Ideas Weblinks Pedagogical Hints
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 of factors such as severity of the disorder, degree of distress faced by others, and the availablity 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.
NATURE AND PROCESS OF PSYCHOTHERAPY
Psychotherapy is a voluntary relationship between the one seeking treatment or the client and the one who treats or the therapist. The purpose of the relationship is to help the client to solve the psychological problems being faced by her or him. The relationship is conducive for building the trust of the client so that problems may be freely discussed. Psychotherapies aim at changing the maladaptive behaviours, decreasing the sense of personal distress, and helping the client to adapt better to her/his environment. Inadequate marital, occupational and social adjustment also requires that major changes be made in an individual's personal environment.
All psychotherapeutic approaches have the following characteristics: (i) there is systematic application of principles underlying the different theories of therapy, (ii) persons who have received practical training under expert supervision can practice psychotherapy, and not everybody.
An untrained person may unintentionally cause more harm than any good, (iii) the therapeutic situation involves a therapist and a client who seeks and receives help for her/his emotional problems (this person is the focus of attention in the therapeutic process), and (iv) the interaction of these two persons - the therapist and the client — results in the consolidation/formation of the therapeutic relationship. This is a confidential, interpersonal, and dynamic relationship. This human relationship is central to any sort of psychological therapy and is the vehicle for change.
All psychotherapies aim at a few or all of the following goals:
(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. It is neither a passing acquaintance, nor a permanent and lasting relationship. There are two major components of a therapeutic alliance. The first component is the contractual nature of the relationship in which two willing individuals, the client and the therapist, enter into a partnership which aims at helping the client overcome her/his problems. The second component of therapeutic alliance is the limited duration of the therapy. This alliance lasts until the client becomes able to deal with her/his problems and take control of her/his life. This relationship has several unique properties. It is a trusting and confiding relationship. The high level of trust enables the client to unburden herself/himself to the therapist and confide her/his psychological and personal problems to the latter. The therapist encourages this by being accepting, empathic, genuine and warm to the client. The therapist conveys by her/his words and behaviours that s/he is not judging the client and will continue to show the same positive feelings towards the client even if the client is rude or confides all the 'wrong' things that s/he may have done or thought about. This is the unconditional positive regard which the therapist has for the client. The therapist has empathy for the client. Empathy is different from sympathy and intellectual understanding of another person's situation. In sympathy, one has compassion and pity towards the suffering of another but is not able to feel like the other person. Intellectual understanding is cold in the sense that the person is unable to feel like the other person and does not feel sympathy either. On the other hand, empathy is present when one is able to understand the plight of another person, and feel like the other person. It means understanding things from the other person's perspective, i.e. putting oneself in the other person's shoes. Empathy enriches the therapeutic relationship and transforms it into a healing relationship.
The therapeutic alliance also requires that the therapist must keep strict confidentiality of the experiences, events, feelings or thoughts disclosed by the client. The therapist must not exploit the trust and the confidence of the client in anyway. Finally, it is a professional relationship, and must remain so.
A classmate or friend of yours or your favourite character in a TV serial may have recently experienced a negative or a traumatic life event (e.g., death of a loved one, break-up of an important friendship or relationship) of which you are aware. Try to put yourself in the other person's shoes, try to experience how that person is feeling, what s/he is thinking and try to take her/his perspective of the entire situation. This will help you to understand better how that person is feeling.
(Note : This exercise may be done in class, so that teachers can help students in overcoming any distress experienced).
TYPE OF THERAPIES
Though all psychotherapies aim at removing human distress and fostering effective behaviour, they differ greatly in
concepts, methods, and techniques. Psychotherapies may be classified into three broad groups, viz. the psychodynamic, behaviour, and existential psychotherapies. In terms of the chronological order, psychodynamic therapy emerged first followed by behaviour therapy while the existential therapies which are also called the third force, emerged last. The classification of psychotherapies is based on the following parameters:
- What is the cause, which has led to the problem?
Psychodynamic therapy is of the view that intrapsychic conflicts, i.e. the conflicts that are present within the psyche of the person, are the source of psychological problems. According to behaviour therapies, psychological problems arise due to faulty learning of behaviours and cognitions. The existential therapies postulate that the questions about the meaning of one's life and existence are the cause of psychological problems.
How did the cause come into existence? In the psychodynamic therapy, unfulfilled desires of childhood and unresolved childhood fears lead to intrapsychic conflicts. The behaviour therapy postulates that faulty conditioning patterns, faulty learning, and faulty thinking and beliefs lead to maladaptive behaviours that, in turn, lead to psychological problems. The existential therapy places importance on the present. It is the current feelings of loneliness, alienation, sense of futility of one's existence, etc., which cause psychological problems.
What is the chief method of treatment? Psychodynamic therapy uses the methods of free association and reporting of dreams to elicit the thoughts and feelings of the client. This material is interpreted to the client to help her/him to confront and resolve the conflicts and thus overcome problems. Behaviour therapy identifies the faulty conditioning patterns and sets up alternate behavioural contingencies to improve behaviour. The cognitive methods employed in this type of therapy challenge the faulty thinking patterns of the client to help her/him overcome psychological distress. The existential therapy provides a therapeutic environment which is positive, accepting, and nonjudgmental. The client is able to talk about the problems and the therapist acts as a facilitator. The client arrives at the solutions through a process of personal growth.
What is the nature of the therapeutic relationship between the client and the therapist?
Psychodynamic therapy assumes that the therapist understands the client's intrapsychic conflicts better than the client and hence it is the therapist who interprets the thoughts and feelings of the client to her/him so that s/he gains an understanding of the same. The behaviour therapy assumes that the therapist is able to discern the faulty behaviour and thought patterns of the client. It further assumes that the therapist is capable of finding out the correct behaviour and thought patterns, which would be adaptive for the client. Both the psychodynamic and the behaviour therapies assume that the therapist is capable of arriving at solutions to the client's problems. In contrast to these therapies, the existential therapies emphasise that the therapist merely provides a warm, empathic relationship in which the client feels secure to
explore the nature and causes of her/ his problems by herself/himself.
What is the chief benefit to the client? Psychodynamic therapy values emotional insight as the important benefit that the client derives from the treatment. Emotional insight is present when the client understands her/his conflicts intellectually; is able to accept the same emotionally; and is able to change her/his emotions towards the conflicts. The client's symptoms and distresses reduce as a consequence of this emotional insight. The behaviour therapy considers changing faulty behaviour and thought patterns to adaptive ones as the chief benefit of the treatment. Instituting adaptive or healthy behaviour and thought patterns ensures reduction of distress and removal of symptoms. The humanistic therapy values personal growth as the chief benefit. Personal growth is the process of gaining increasing understanding of oneself, and one's aspirations, emotions and motives.
What is the duration of treatment? The duration of classical psychoanalysis may continue for several years. However, several recent versions of psychodynamic therapies are completed in 10-15 sessions. Behaviour and cognitive behaviour therapies as well as existential therapies are shorter and are completed in a few months.
Thus, different types of psychotherapies differ on multiple parameters. However, they all share the common method of providing treatment for psychological distress through psychological means. The therapist, the therapeutic relationship, and the process of therapy become the agents of change in the client leading to the alleviation of psychological distress. The process of psychotherapy begins by formulating the client's problem. Steps involved in the formulation of a client's problem are given in Box 5.1.
Steps in the Formulation of a Client's Problem
Clinical formulation refers to formulating the problem of the client in the therapeutic model being used for the treatment. The clinical formulation has the following advantages:
- Understanding of the problem: The therapist is able to understand the full implications of the distress being experienced by the client.
- 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 assertiveness skills and anxiety. The target areas have thus been identified as inability to assert oneself and heightened anxiety.
- 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.
Gather information about some institutions you know which offer psychiatric/psychotherapeutic help.
The following sections explain different types of therapies three major