Module 1: Introduction to

Psychotherapy
unit 1
Psychotherapy may be defined as the treatment of emotional and
personality problems and disorders by Psychological means (Kolb, 1968).
According to Wolberg (1967) psychotherapy is the treatment, by
psychological means, of problems of an emotional nature in which a
trained person deliberately establishes a professional relationship with the
patient with the object a) of removing, modifying or retarding existing
symptoms b) of mediating disturbed patterns of behaviour and c) of
promoting positive personality growth and development. From above
definitions it is apparent that there is wide agreement that by
psychotherapy are meant those therapeutic techniques which can be called
psychological in the treatment of problems of an emotional or
psychological nature.

Varieties of psychotherapy

Supportive therapy
Reeducative therapy
Reconstructive therapy

Supportive therapy
Supportive psychotherapy is a dyadic treatment that uses direct
measures to ameliorate symptoms and to maintain, restore, or
improve self-esteem, ego functions, and adaptive skills Supportive
psychotherapy is a kind of therapy most physicians can offer their
patients. It aims to improve symptoms and maintain, restore or
improve self-esteem and skills. Supportive psychotherapy is the
attempt by a therapist, by any practical means, to help patients deal
with their emotional distress and problems in living. It includes
comforting, advising, encouraging, reassuring, and mostly listening,
attentively and sympathetically. Supportive techniques are general
measures that comfort and guide the client. They are directed at
reducing client-distress without specifically addressing the
psychological and behavioural causes. Thus, supportive procedures
are non-specific in nature. Douglas asserted, “supportive therapy has
not been sufficiently well defined in a manual or tested in controlled
clinical trials to be considered evidence based” Supportive
psychotherapy is a psychotherapeutic approach that integrates various
therapeutic schools such as psychodynamic and cognitive-
behavioural, as well as interpersonal conceptual models and
techniques.

Reeducative therapy
a form of psychological treatment in which the client learns effective
ways of handling and coping with problems and relationships through
a form of no reconstructive therapy, such as relationship therapy,
behaviour therapy, persuasion therapy, nonanalytic group therapy, or
reality therapy. A form or stage of psychotherapy in which the patient
is taught or, better allowed to learn to himself more effective ways of
dealing with problems and relationships. It can be effective only by
modifying the patient’s feelings and reactions. The patient gradually
learns how to handle a social situation, marital, or occupational
problem that has causes stress and anxiety Examples of this type of
therapy include short-term, solution-oriented, reality, cognitive
restructuring, and behaviour modification.

Re-constructive psychotherapy

Re-constructive therapy is contrasted with supportive therapy and it

is also distinguished from re-educative therapy. However, the line
between the three approaches is not a sharp one, since supportive and
re-educative therapy may have a constructive effect and the re-
constructive approach always contains supportive and re-educative
components. In this therapy, the relief of symptoms is indirectly
achieved since it comes about through a revision or reorganization of
the patient’s basic attitudes toward himself as well as his relationship
with other people-constructive therapy is a form of therapy, such
as that seek not only to alleviate symptoms but also to produce
alternations in maladaptive character structure and to expedite new
adoptive potentials; this aim is achieved by bringing into
consciousness and awareness of insight into conflicts, fears,
inhibition, and their manifestation. Re-constructive psychotherapy is
directed toward basic and extensive modification of an individual’s
character structure by enhancing his/her insight into development
and adaptive responses. The re-constructive style of therapy is
systematic, discriminating, and objective. The style is systematic in
that it has an opening, a middle and an end.
The re-constructive style of therapy contains many of the
conventional characteristics of psychotherapy in which the therapist
focuses on manifest and dynamic content. Manifest content refers to
the client’s overt expression – his verbal communication and that
 aspect of behaviour that can be seen – (his expressive movements,
postures, initial reactions, and personal mannerisms). Dynamic
content is essentially influential – the inferred forces that are
presumably purposive for the behaviour observed, for example,
hostility, guilt, or depression.
The goal of re-constructive therapy, through identifying manifest
content and dynamic content is to reshape the client’s learned
behaviour pattern of coping with non-productive problems.

unit 2
Stages and outline of psychotherapy
1) Pairing

Empathy, positive regard and affirmation, congruence and genuineness,

goal consensus, and collaboration are crucial for success. As clients, these
elements help us build enough trust in our therapist to take the often scary
step out of our problem and into a therapeutic alliance with our therapist.
This phase also helps to build hope, as discussed in my post "Hope: A
Foundation of all Psychotherapy that Works."
Stories, frames, and metaphors shared by our therapist help us see our
problems as human and help us see our therapists as simply human
themselves. Therapists and clients are looking for a close match or fit with
each other. The closer our therapist matches our values, language,
metaphors, and our position on the problem, the better the fit.
2) Recognizing Patterns

All therapists look for repetitive patterns in their clients’ lives. These
include both positive and problematic patterns. It is just as important to
build on clients' strengths, as it is to address their identified problems. My
post, "Nine Dots: A Key to Psychological Problems?" covers the essence of
these vicious cycle patterns.
Here, therapists ask clients to define their problem, ask what they have
done about it, find out what they usually do about it, how that has typically
worked, and what others have tried to do or suggested for them to do about
it (including what other therapists have suggested). Identifying vicious
cycle patterns is the ultimate target. Vicious cycle patterns in couples, for
example, and commonly effective therapies to resolve them may be found
in the post, "What Do All Troubled Couples Share?"

3) Orienting Toward Change

Clear, agreed-upon goals are strongly associated with successful therapy
across all approaches. In all therapies, therapists target exactly what shifts
clients need to make in their problem patterns. The therapist needs to know
the pattern of the vicious cycle to understand how to shift it. The classic
vicious cycles around depression, for example, can be tracked in the post
"The Two Faces of Depression."

The therapist’s theoretical position on problems and their rationale for

treatment come in here as well. This is the point when therapists need to
align with what will make sense to us as clients and engage us in an
alliance for change. This leads to the next phase of collaboration and
building a therapeutic alliance.
4) Collaborating on a Plan

The work of therapy is done through alliance—collaboration. Finding the

best fit between client and therapist on an understandable, sensible, and
workable frame and rationale for treatment is crucial to building a strong
alliance. Frames and rationales may include theoretical explanations,
research-based explanations, developmental explanations, frames fitting
spiritual or cultural traditions, and many more. Of course, the closer the
frame fits our worldview, values, and beliefs the better. This is the focus of
the post, "The Hero's Journey: Finding Therapy That Fits."

5) Engaging Treatment

Treatment often begins before treatment starts: Saying that treatments start
at a set stage to engage treatment isn't really right. In fact, treatment begins
at times even before the first session. Clients may have gotten a
recommendation to a given practitioner based upon their reputation for
success, creating a halo of hope even before seeing the therapist. In many
ways, the same can be said about the other preceding phases—each step
often starts before a client even meets their therapist.
Assessment & treatment are inseparable: Similarly, therapists’ theoretical
perspective shapes the type of questions they ask, what they attend to,
follow up on, and even whom they may include in sessions. Assessment
and intervention are essentially inseparable. They influence and shape the
course of interaction and information in an evolving co-created “truth”
about the clients’ problem as well as about the therapist. The dance of
intervention, so to speak, begins immediately. Therapist interests through
the early part of any session may focus on history, on interpersonal
relationships, on thoughts and beliefs, on pure behavior sequences, social
networks, on the way the client reacts in the moment to the therapist, or
combinations of all of these and more.

Treatment rationales guide interventions: The rationale our therapist used

to explain therapy creates a framework for treatment. As that treatment
rationale makes sense to us, so does the fit between clients and therapists.
Interventions and procedures must make sense to both clients and
therapists because those new solutions often seem counterintuitive from
our original understanding of our problem.

Interventions must shift problem patterns: What matters is that the

interventions create new shifts to initiate virtuous cycle patterns. Treatment
techniques and procedures may include, for example, in-session
enactments, two-chair dialogues, Socratic questioning, modeling,
rehearsals, in-session bonding and affirmations, interpretations, homework
assignments, and a range of other specific treatment techniques. What
matters is that those interventions shift our problem-generating solutions.

6) Supporting Success

All effective therapists note and support positive pattern shifts, and support
client ownership of those changes. The goal is to support an evolving
virtuous cycle consistent with agreed-upon goals. Client ownership of these
changes is important across treatments. In many ways, most treatments
explain problems as reasonable reactions to the course of historical and
current stressors and events. It doesn't matter if the type of treatment is
dynamic, interpersonal, behavioral, cognitive, emotional, or other frames
and explanations. However, they consistently affirm the clients’ distress as
a product of their situation and their treatment successes as due to the
client's own efforts.
Change as Personal, Positive & Pervasive: Most treatments cast problem
patterns, while distressing and understandably negative, as transient and
situational. The movement is from clients viewing their problems as
personal, negative, and pervasive to owning their strengths, resilience, and
successes in the face of such adversity as personal, positive, and pervasive.

7) Sustaining the Change

All evidence-supported treatments include some final phase where they

build resilience and engage in relapse prevention. All treatments
acknowledge the potential for future life challenges and potential relapse
into the original problem cycles. The goals of all treatments are to sustain
changes once they occur and continue the virtuous cycles.

Predicting & Prescribing: Most all successful treatments use the idea of
predicting and prescribing as treatment concludes.

Predicting: Clinicians usually warn clients of the hurdles ahead. They

discuss future challenges and even rehearse responses in sessions. Under
the idea that “forewarned is forearmed,” clients and therapists collaborate
as they predict future obstacles.

Prescribing: Turning to the idea of prescribing, the usual approach before

ending treatment is, once clients have developed a new, sustained patterned
resolution, to have clients actively confront old situations, thoughts, and
emotions. First, if clients find themselves relapsing into old patterns, they
learn something they can discuss and address in following sessions.
Second, deliberately trying to reengage in old responses, formerly viewed
as coming on spontaneously, offers another paradox. It's reassuring not to
be able to bring on the old problem. It is contradictory, for example, to have
a panic attack in a controlled and deliberate way.

The Family Doctor Model: In most contemporary treatments, therapists

cast themselves in the same light as family practitioners. Clients always
assume they will return to a trusted family doctor after recovering from a
recent illness. This goes as well for psychotherapists. Most therapists now
welcome clients back for booster sessions—a practice actively supported
by the literature.

Basic ingredients of psychotherapy

Emotionally upset people are constantly being assisted in achieving

homeostatic equilibrium through a variety of approaches. Taking a
vacation, changing jobs, confiding in a concerned and wise friend,
consulting a minister, swallowing tranquilizing substances, adopting a
different philosophical outlook, and talking to a professional consultant all
seem to bring relief. Both informal approaches and formal psychotherapy
are helpful. The soothing embraces of a human relationship, the automatic
arousal of a magical placebo element, and the releasing powers of
emotional catharsis are parcels that may bring a person to an adaptive
equilibrium. The method is non-specific and diverse: it could be amulet,
pill, environmental change, homely philosophy, systematized dogma, or
scientific method.

But the fact that any contact between two human beings or that any device,
appliance, or technique seems to bring relief does not justify our applying
the label of psychotherapist to the healer and psychotherapy to the tactic.
People are abidingly achieving relief from symptoms in a propitious
environment. But only rarely—and this is most fortuitous—do they acquire
a significant enrichment of their behavioral or creative potentials. What we
are concerned with is the studied manipulation of forces in a professional
relationship that can, in addition to restoring homeostatic equilibrium,
bring about behavioral and personality change with greater frequency than
would occur by chance or through the activities of nonprofessional
“helping” agencies or professional counseling

One of the great bewilderments in appraising the virtues of psychotherapy

is the difficulty of assigning to it specific processes and effects apart from
the non-specific instrumentalities of “helping” and the subsidies of
casework and counseling. In practice, the techniques of helping,
counseling, and psychotherapy merge imperceptibly; as to effects, it is
generally impossible to apportion the degree of improvement brought about
by non-specific and specific moieties. Nevertheless, it is of more than
heuristic value to attempt to distinguish aspects of relating to which we
may affix the term “psychotherapeutic” as differentiated from counseling
and helping.
Psychotherapeutic-like services are often rendered without intent by
persons with no training whatsoever. For example, what would one call the
ministrations of an individual who is visited regularly—sometimes as often
as six times weekly—by a steady “clientele” suffering from a wide range of
psychiatric syndromes, a person who serves the purpose of relieving their
emotional symptoms by:

(1) Dispensing a tranquilizing substance more effective than the most

powerful psychotropic drug

(2) Relating with the clientele, variantly reassuring, guiding, advising, and
interpreting.
The “clients” in turn interact with this administrative individual as well as
with the souls around them, participating in the boons associated with
placebo influence, suggestion, and group dynamics. Under the influence of
the “tranquilizing drug” their resistances are softened, and they are apt to
express themselves volubly, often with free associations, experiencing
emotional catharsis, exhibiting transference reactions (sometimes an actual
transference neurosis), revealing aspects of their unconscious, and
occasionally exhibiting acting-out tendencies that are usually dealt with
firmly by the individual in charge. No patients are more dedicated to their
“sessions” than are these clients. The individual to whom I refer practices
the skills daily in every local bar in the country; his steady clients are
among the sickest individuals in our society. There are probably more
bartenders functioning in the role of psychotherapists in this country than
there are psychiatrists, psychologists, and psychiatric social workers
combined. Yet they dispense their medicaments without prescription, and
they go through their interviewing maneuvers with no psychiatric
supervision whatsoever. To call such an individual a psychotherapist is
obviously preposterous, and to dignify his activities as a form of
psychotherapy would be a disservice to the art. This is only one example
(and there are many) of untutored helping agencies to whom an
emotionally upset individual may turn who may serve a therapeutic like
function.

UNIT 3 – PSYCHOTHERAPIST AND

PSYCHOTHERAPY CLIENT,
PSYCHOTHERAPEUTIC RELATIONSHIP
THERAPIST VARIABLES
PERSONALITY FACTORS
Untrained person with a concerned manner and empathic personality
will get better immediate results, especially with sicker patients, than
a highly trained therapist who manifests a “deadpan” detached
professional attitude. One should not assume from this that a
therapist with a pleasing personality without adequate training will
invariably get good results. Some of the available research alerts us
to the fact that the level of therapist expectations and the triad of
empathy, warmth, and genuineness do not invariably represent the
“necessary and sufficient” conditions of effective therapy. A well-
trained therapist, however, who also possesses the proper
“therapeutic” personality is by far best qualified to do successful
therapy and should be also consider some other variables also since
we may be dealing here with different classes of patients, i.e.,
patients seeking a warm, giving authority as contrasted to those who
want less personal involvement and greater ability to probe for and
resolve defenses in quest of more extensive self-understanding.
Two personality qualities are especially undesirable in a therapist
doing therapy:
*First and most insidious is detachment. A detached therapist will be
unable, within the time span of treatment, to relate to the patient or to
become involved in the essential transactions of therapeutic process.
A detached person finds it difficult to display empathy. To put it
simply, one cannot hatch an egg in a refrigerator. A cold emotional
relationship will not incubate much change in treatment.
* second quality that inimical to doing good therapy is excessive
hostility. Where therapists are angry people, they may utilize select
patients as targets for their own irritations. A patient has enough
trouble with personal hostility and may not be able to handle that of
the therapist. A therapist, exposed to a restrictive childhood, having
been reared by hostile parents, or forbidden to express indignation or
rage, is apt to have difficulties with a patient who has similar
problems. Thus the patient may be prevented from working through
crippling rage by the subtle tactic of the therapist changing the
subject when the patient talks about feeling angry, or by excessive
reassurance verbal attack on the patient, or by making the patient feel
guilty.
CHOICE OF TECHNIQUES
Technical preferences by therapists are territories ruled by personal
taste rather than by objective identifiable criteria. As has been
previouslyindicated,it matters lit-tie how scientifically based a
system of psychotherapy may be or how skilfully it is implemented-if
a patient does not accept it, or if it does not deal directly or indirectly
with the problems requiring correction, it will fail. Because of the
complex nature of human behavior, aspects that are pathologically
implicated may require special interventions before any effect is
registered. Prescribing a psychotropic drug like lithium for an excited
reaction in a psychopathic personality will not have the healing effect
that it would have in violent outbursts of a manic-depressive disorder.
Unfortunately, some therapists still cling to a monolithic system into
which they attempt to wedge all patients, crediting any failure of
response to the patient’s resistance.
SKILL AND EXPERIENCE IN THE IMPLEMENTATION OF
TECHNIQUES
The history of science is replete with epic struggles between
proponents of special conceptual systems. Contemporary
psychotherapists are no exception. In a field as elusive as mental
health it is little wonder that we encounter a host of therapies, some
old, some new, each of which proposes to provide all the answers to
the manifold problems plaguing mankind. A scrupulous choice of
techniques requires that they be adapted to the needs and learning
capacities of patients and be executed with skill and confidence.
Understandably, therapists do have predilection’s for certain
approaches and they do vary in their facility for utilizing them. Faith
in and conviction about the value of their methods are vital to the
greatest success. Moreover, techniques must be implemented in an
atmosphere of objectivity.
To function with greatest effectiveness, the therapist should ideally
possess a good distribution of the following:
Extensive training : Training in many parts of the country, has
become parochial, therapists becoming wedded to special
orientations that limit their use of techniques. Accordingly, patients
become wedged into restricted interventions and when they do not
respond to these the therapeutic stalemate is credited to resistance.
Over and over, experience convinces that sophistication in a wide
spectrum of techniques can be rewarding, especially if these are
executed in a dynamic framework. Whether personal psychoanalysis
is essential or not will depend on what anxieties and personal
difficulties the therapist displays in working with patients. The fact
that the therapist does not resort to the discipline of formal analytic
training does not imply being doomed to doing an inferior kind of
therapy. Indeed, in some programs, where the analytic design is
promoted as the only acceptable therapy, training may be
counterproductive. Nevertheless, ifa therapist does take advantage of
a structured training program, which includes exposure to dynamic
thinking and enough personal therapy to work out characterologic
handicaps, this will open up rewarding dimensions, if solely to help
resolve intrapsychic and interpersonal conflicts that could interfere
with an effective therapeutic relationship. Irrespective of training,
there is no substitute for management under supervision of the wide
variety of problems that potentially present themselves. It is
important that therapists try to recognize their strong and weak points
in working with the various syndromes. No matter how well adjusted
therapists may be, there are some critical conditions that cannot be
handled as well as others. They may, when recognizing which
problems give the greatest difficulties, experiment with ways of
buttressing shortcomings.
Flexibility in approach : A lack of personal investment in any one
technique is advantageous. This requires an understanding of the
values and limitations of various procedures (differential
therapeutics), experience in utilizing a selected technique as a
preferred method, and the blending of a variety of approaches for
their special combined effect. Application of techniques to the
specific needs of patients at certain times, and to particular situations
that arise, will require inventiveness and willingness to utilize the
important contributions to therapeutic process of the various
behavioral sciences, accepting the dictum that no one school has the
monopoly on therapeutic wisdom.

PATIENT VARIABLES

THE SYNDROME OR SYMPTOMATIC COMPLAINT

By and large techniques do operate as a conduit through which a

variety of healing and learning processes are liberated. How the
techniques are applied, the faith of therapists in their methods, and
the confidence of the patient in the procedures being utilized will
definitely determine the degree of effectiveness of a special
technique. But techniques are nevertheless important in themselves
and experience over the years with the work of many therapists
strongly indicates that certain methods score better results with
special problems than other methods. Where repressions are extreme,
classical psychoanalysis, intense confrontation, hypnoanalysis,
narcoanalysis, and encounter groups have been employed in the
attempt to blast the way through to the offensive pathogenic areas.
Understandably. Patients with weak ego structures are not candidates
for such active techniques, and therapists implementing these
techniques must be stable and experienced. Antisocial personalities
subjected to a directive, authoritarian approach with a firm but kindly
therapist sometimes manage to restrain their acting-out, but require
prolonged supervised overseeing.

Apart from the few selected approaches pointed out above that are
preferred methods under certain circumstances, we are led to the
conclusion that no one technique is suitable for all problems. Given
conditions of adequate patient motivation and proper therapist skills,
many different modalities have yielded satisfactory results. It is my
feeling however, that whatever techniques are employed, they must
be adapted to the patient’s needs and are most advantageously
utilized within a dynamic framework.

Transference reactions may come through with any of the techniques,

even with biofeedback and the physical therapies. Alerting oneself
for transference, one must work with it when it operates as resistance
to the working relationship. Unless this is done our best alignment of
method and syndrome will prove useless. The fact that certain
techniques have yielded good results with special syndromes and
symptoms does not mean they will do so for all therapists or for
every patient. Interfering variables, such as will henceforth be
described, will uniquely block results or will make the patient
susceptible to other less popular methods.
SELECTIVE RESPONSE OF THE PATIENT TO THE THERAPIST

At its core the patient’s reaction to the therapist often represents how
the patient feels about authority in general, such emotions and
attitudes being projected onto the therapist even before the patient
has had his first sessions. The patient may rehearse in advance what
to say and how to behave, setting up imaginary situations in the
encounter to come. Such a mental set will fashion feelings that can
influence the direction of therapy. Thus, if the patient believes that
authority is bad or controlling, oppositional defenses may be apparent
during the interview. These global notions about authority and the
reactions they sponsor are usually reinforced or neutralized by the
response to the therapist as a symbol of an actual person important to
the patient in the past (transference). Some characteristic in the
therapist may represent a quality in a father or mother or sibling and
spark off a reaction akin to that which actually had occurred in past
dealings with the person in question. Or the reaction may be
counteracted by a defense of gracious compliance or guarded
formality. Confidence in one’s therapist is enormously important-
even when the therapist’s ideas of the etiology or dynamics of the
patient’s difficulty are wrong. The patient’s acceptance of
explanations proffered with conviction can have a determining
influence on the patient. They are incorporated into the patient’s
belief system and sponsor tension reduction and restoration of
habitual defenses. Through what means this alchemy takes place is
not clearly known, but suggestion, the placebo effect, and the impact
of the protecting relationship offered by the therapist undoubtedly
play a part. Sometimes unpredictable elements operate in the
direction of cure.
SELECTIVE RESPONSE OF THE PATIENT TO THE THERAPIST’S
TECHNIQUES

Patients occasionally have preconceptions and prejudices about

certain techniques. Hypnosis, for example, may be regarded as a
magical device that can dissolve all encumbrances, or it may connote
exposing oneself to Svengali-like dangers of control or seduction.
Misconceptions about psychoanalysis are rampant in relation to both
its powers and its ineffectualities. Frightening may be the idea that
out of one’s unconscious there will emerge monstrous devils who will
take command-for example, the discovery that one is a potential
rapist, pervert, or murderer. Should the therapist have an inkling as to
what is on the patient’s mind, clarification will then be in order. The
manner of the therapist’s style is also apt to influence reactions of
rage at the therapist’s passivity, balkiness at what is considered too
intense activity, anger at aggressive confrontation. Some patients are
frustrated by having to talk about themselves and not being given the
answers.
Since psychotherapy is in a way a form of reeducation, the learning
characteristics of a patient should best correspond with the
techniques that are to be used. Problem-solving activities are often
related to the kind of processes found successful in the past. Some
patients learn best by working through a challenge by themselves,
depending to a large extent on experiment. Some will solve their
dilemmas by reasoning them out through thinking of the best solution
in advance. Others learn more easily by following suggestions or
incorporating precepts offered by a helpful authority figure. Some are
helped best by modeling themselves after an admired person, through
identification with that person. Some patients work well with free
association,others do not. Some are able to utilize dreams
productively, or behavior modification, or sensitivity training or other
methods. It would seem important to make the method fit the patient
and not wedge the patient into the method.
While empirical studies tell us little about factors that make for a
good patient therapist match, we may speculate that the personalities,
values, and physical characteristics of both patient and therapist must
be such that severe transference and unfavorable countertransference
problems do not erupt to interfere with the working relationship. A
giving accepting warm, and active but not too interfering or
obnoxiously confronting manner in the therapist is most conducive to
good results
.
READINESS FOR CHANGE

Another important factor is the individual’s readiness for change.

This is a vast unexplored subject. A person with a readiness for
change will respond to almost any technique and take out of that
technique what he or she is prepared to use. What components enter
into a satisfactory readiness for change have not been exactly
defined, but they probably include a strong motivation for therapy, an
expectation of success, an availability of flexible defenses, a
willingness to tolerate a certain amount of anxiety and deprivation,
the capacity to yield secondary gains accruing from indulgence of
neurotic drives, and the ability either to adapt to or constructively
change one’s environment Patients come to therapy with different
degrees of readiness to move ahead. Some have worked out their
problems within themselves to the extent that they need only a little
clarification to make progress, perhaps only one or two sessions of
therapy. Others are scarcely prepared to proceed and they may require
many sessions to prepare
themselves for some change. We may compare this to climbing a
ladder onto a platform. Some people are at the bottom of the ladder
and before getting to the top will need to climb many steps. Others
will be just one rung from the top, requiring only a little push to send
them over to their destination.
In therapy we see people in different stages of readiness for change,
and we often at the start are unable to determine exactly how far they
have progressed. One may arrive at an understanding of what is
behind a patient’s problem rapidly. From this we may get ar idea that
benefits will occur with little delay. Yet in relation to readiness for
change, the patient may still be at the bottom of the ladder. Others are
at a point where almost any technique one happens to be using will
score a miracle. We may then overvalue the technique that seems to
have worked so well and apply it to many different patients with such
conviction that the placebo effect produces results.
DEGREE AND PERSISTENCE OF CHILDISH DISTORTIONS

The distorted images of childhood, the ungratified needs, the

unwholesome defenses, may persist into adult life and influence the
speed, direction, and goals of therapy. These contaminations may
obtrude themselves into the therapeutic situation irrespective of what
kinds of technique are practiced. Insidiously, they operate as
resistance and they can thwart movement toward a mature
integration, no matter how persistent and dedicated the therapist may
be. Where severe traumas and deprivations are sustained in early
infancy, especially prior to the acquisition of language, the damage
may be so deep that all efforts to acquire that which never developed
and to restore what never existed will fail. Transference with the
therapist may assume a disturbingly regressive form and, while the
genetic discoveries may be dramatic, the patient, despite intellectual
understanding. Will not integrate any learning and will fail to
abandon patterns that end only in disappointment and frustration.
Very little can be accomplished under such circumstances in short-
term therapy, and even long-term depth therapy may lead to nothing
except a transference neurosis that is difficult to manage or resolve.
Lest we be too pessimistic about what may be accomplished through
psychotherapy, there are some patients who, though seriously
traumatized, may when properly motivated be induced to yield the
yearnings of childhood and to control if not reverse the impulses
issuing from improper discipline and unsatisfied need gratification.
But this desirable achievement will require time, patience and, above
all, perseverance.

APTITUDE FOR DYNAMICALLY ORIENTED PSYCHOTHERAPY

Practically all people who apply for help in managing emotional

problems can be approached successfully with supportive and
educational therapies. Eligibility for dynamically oriented treatment,
however, requires some special characteristics. Some of the available
research indicates that patients who respond best to
psychodynamically oriented therapy need treatment the least. What
this would imply is that persons with good ego strength can somehow
muddle along without requiring depth therapy. That this is not always
so becomes obvious when we examine the quality of adaptation of
these near-to-healthy specimens. In view of the shortage of trained
manpower, we may want to look for characteristics in prospective
candidates for therapy that have good prognostic value.
The following positive factors have been emphasized:
1. Strong motivation for therapy (actually coming to therapy
represents some commitment)
2. Existence of some past successes and positive achievements
3. Presence of at least one good relationship in the past
4. A personality structure that has permitted adequate coping in the
past
5. Symptomatic discomfort related more to anxiety and mild
depression than to somatic complaints
6. An ability to feel and express emotion
7. A capacity for reflection
8. Desire for self-understanding
9. Adequate preparation for therapy prior to referral
10. Belief systems that accord with the therapist’s theories.
The patient’s expectations, age, and socioeconomic status are not too
significant, provided the therapist and patient are able to
communicate adequately with each other.

CHOICE OF GOAL AND FOCUS

If a patient through therapy expects to be a Nobel Prize winner, the

patient will be rudely disappointed and soon lose faith in the
therapist. There are certain realistic limits to how much we can
accomplish through treatment, the boundaries largely being
determined by the patient’s dedication to the assigned task. Added to
these are the curbs imposed by the many therapist variables soon to
be considered. A great deal of tact will be required in dealing with
inordinate expectations so as not to undermine further the already
existent devalued self-image The selection by the patient of the area
on which to concentrate during therapy is a legitimate and
understandable theater around which initial interventions can be
organized. It may not be the most culpable area stirring up trouble for
the patient. But to push aside the patient’s concerns with a symptom
or a disturbing life situation and insist on attacking aspects of
problems the patient does not understand or is not motivated to
accept will lead to unnecessary complications and resistances. It is
far better to work on zones of the patient’s interest at the same time
that we make connections for the patient and educate the need to deal
with additional dimensions.
In attempting to choose the most productive arena for intervention we
must keep in mind the fact that behavior is a complex integrate of
biochemical, neuro-physiological, developmental, conditioning,
intrapsychic, interpersonal, social, and spiritual elements intimately
tied together like links in a chain. Problems in one link cybernetically
influence other links.

PSYCHOTHERAPEUTIC RELATIONSHIP

The therapeutic relationship refers to the relationship between a

healthcare professional and a client or patient. It is the means by
which a therapist and a client hope to engage with each other and
effect beneficial change in the client. The therapeutic relationship is
the connection and relationship developed between the therapist and
client over time. Without the therapeutic relationship there can be no
effective or meaningful therapy. This applies to all forms of
counselling and psychotherapy, and regardless of the theoretical
orientation of your therapist or counsellor, the relationship developed
between you will be considered of high importance. There are mainly
three major elements in therapeutic alliance.

Resistance
Transference
Counter transference
RESISTANCE: Resistance is loosely defined as a client’s
unwillingness to discuss a particular topic in therapy. For example, if
a client in psychotherapy is uncomfortable talking about his or her
father, they may show resistance around this topic.
TRANSFERENCE : Transference is a phenomenon within
psychotherapy in which the feelings a person had about their parents,
as one example, are unconsciously redirected or transferred to the
present situation. It usually concerns feelings from a primary
relationship during childhood.
COUNTER TRANSFERENCE : counter-transference occurs when the
therapist projects their own unresolved conflicts onto the client. This
could be in response to something the client has unearthed. Although
many now believe it to be inevitable, counter-transference can be
damaging if not appropriately managed.

ROGERIAN THERAPEUTIC ALLIANCE

According to Rogers (1977), three characteristics, or attributes, of the
therapist form the core part of the therapeutic relationship –
congruence, unconditional positive regard (UPR) and accurate
empathic understanding.
Congruence: Congruence is the most important attribute, according to
Rogers. This implies that the therapist is real and/or genuine, open,
integrated and authentic during their interactions with the client. The
therapist does not havea façade, that is, the therapist’s internal and
external experiences are one in the same. In short, the therapist is
authentic. This authenticity functions as a model of a human being
struggling toward greater realness. However, Rogers ’concept of
congruence does not imply that only a fully self-actualized therapist
can be effective in counseling (Corey, 1986). Since therapists are also
human, they cannot be expected to be fully authentic. Instead, the
person-centered model assumes that, if therapists are congruent in the
relationship with the client, then the process of therapy will get under
way…Congruence exists on a continuum rather than on an all-or-
nothing basis (Corey, 1986).
Unconditional Positive Regard (UPR): This refers to the therapist’s
deep and genuine caring for the client. The therapist may not approve
of some of the client’s actions but the therapist does approve of the
client. In short, the therapist needs an attitude of “I’ll accept you as
you are.”
According to Rogers (1977), research indicates that, the greater the
degree of caring, prizing, accepting, and valuing the client in a no
possessive way, the greater the chance that therapy will be
successful…BUT, it is not possible for therapists to genuinely feel
acceptance and unconditional caring at all times (Corey, 1986).
Accurate Empathic Understanding: This refers to the therapist’s
ability to understand sensitively and accurately [but not
sympathetically] the client’s experience and feelings in the here-and-
now. Empathic understanding implies that the therapist will sense the
client’s feelings as if they were his or her own without becoming lost
in those feelings (Corey, 1986).
In the words of Rogers (1975), accurate empathic understanding is as
follows: “IfI am truly open to the way life is experienced by another
person…if I can take his or her world into mine, then I risk seeing
life in his or her way…and of being changed myself, and we all resist
change. Since we all resist change, we tend to view the other person’s
world only in our terms, not in his or hers. Then we analyze and
evaluate it. That’s human nature. We do not understand their world.
But, when the therapist does understand how it truly feels to be in
another person’s world, without wanting or trying to analyze or judge
it, then the therapist and the client can truly blossom and grow in that
climate.”
LUBORSKY, (1976 )
Two types of helping alliances were identified:
Type I, more evident in the beginning of therapy
Type 2, more typical of later phases of treatment.
Type I alliance – “A therapeutic alliance based on the patient’s
experiencing the therapist as supportive and helpful with himself as a
recipient
Type 2 alliance – “ A sense of working together in a joint struggle
against what is impeding the patient on shared responsibility for
working out treatment goal a sense of we-ness”.
Strength of both Type I and Type 2 alliances were associated with the
likelihood of improvement.
COGNITIVE BEHAVIORAL APPROACH

Cognitive-behavior therapy (CBT) stems from learning theories; it

was developed during the second half of the twentieth century. The
CBT approach focuses on the clients’ ways of thinking and behaving,
as well as the relationship between their thoughts, their
actions/reactions, and how they feel. As its name implies, it works by
identifying and modifying the thoughts and behaviors that may be
causing difficulties to the clients, which then helps to improve their
mood. More recently, Acceptance and Commitment Therapy (ACT)
and mindfulness are complementary strategies which have been
added to the CBT approach in order to increase the clients’ capacities
to be present in the moment and to cope with their emotional
insecurity. The goal of CBT is to teach clients that while they cannot
control every aspect of the world around them, they can take control
of how they interpret and deal with things in their environment.
Cognitive-behavior therapy is generally short-term (three to six
months) and focused on helping clients deal with a very specific
problem. During the course of treatment, clients learn how to identify
and modify maladaptive thought patterns that have a negative
influence on their behaviors. The underlying concept behind CBT is
that our thoughts and feelings play a fundamental role in our
behavior.
With the use of evidence-based strategies such as systematic
desensitization or cognitive restructuring, CBT enables clients to be
actively in problem-solving. The CBT approach is commonly used in
the treatment of a wide range of disorders including anxiety disorders
(phobias, generalised-anxiety, etc.), addictions, mood disorders
(depression or mania), communication difficulties, as well as self-
esteem and confidence issues.

ALLIANCE AS PAN – THEORETICAL FACTOR

The alliance has evolved into one of the most researched

psychotherapy process variables. In this paper it is argued that
migration of the concept of the alliance from its psychodynamic roots
onto “Common Factor Land” has brought not only great benefits but
substantial challenges as well. Currently the alliance has no
consensual1 definition, nor has its relation to other relationship
constructs been clearly charted. As a consequence, alliance
assessment tools have been substituted for a concept definition and
taken over the grounds that theorizing about a construct would
normally occupy. The historical background of the events that lead to
the current state are reviewed and some consequences of positioning
the alliance on the conceptual space where Common Factors “live”
are examined. Some possible avenues of moving the alliance project
forward and re-connecting the empirical research to clinical practice
are explored.

FACTORS INFLUENCING ALLIANCE – OUTCOME

Type of treatment
Treatment length
Early versus late alliance
Client and therapist factors
A strong bond is crucial to the success of counselling and
psychotherapy. It can be especially valuable to clients who may have
struggled forming relationships in their past, and those who
 experienced traumatic events in their early years, leading them to
find it difficult to form relationships in adulthood. Therapy allows
clients the chance to explore their relational attachments, bonds and
experiences through their relationship with their therapist, which is
why this relationship is so important. Without the therapeutic
relationship there can be no therapy. Therefore, we know that this is a
crucial part of therapy. In some ways you could say that the
relationship is the therapy. How the client and therapist engage
matters in defining the successes of therapy and counselling. This
relationship is essential to establishing and promoting willingness for
the client to share and engage within the therapeutic space. The
relationship will hopefully allow the client to move toward more
open behaviours and an increased level of self-awareness.

Unit 4
Eclectic approach and Integrative approach
Eclectic approach
Eclectic therapy is a type of therapy that seeks to directly meet the client
and their needs by drawing from multiple therapy approaches in order to
select the best treatment for each individual client. It can be viewed as a
combination of different therapy approaches that is tailored to each client
depending on their problems, goals, and expectations.
This type of therapy is the most common approach to therapy because it is
so versatile.
Gordon Paul, an early proponent of eclectic therapy, captured the essence
of this type of therapy when he described it as an approach that seeks to
determine, “What treatment, by whom, is the most effective for this
individual with that specific problem, under which set of circumstances,
and how does it come about”.
The heart of eclectic therapy involves understanding each client as a unique
person with their own particular problems and then selecting research-
based techniques from across different types of therapy in order to help that
client grow in a personally meaningful way.
? How Eclectic Therapists Select Their Techniques and Underlying
Beliefs?
Despite the fact that it is flexible and pulls from multiple therapeutic
approaches depending on the needs of the client, eclectic therapy is a very
intentional approach to mental health therapy. Therapists purposefully
select techniques based on established criteria.
There are four general concepts that define how therapists choose what they
do:

Theoretical integration
Technical eclecticism
Common factors
Assimilative integration

An eclectic therapist using the theoretical integration method of therapy

adheres to two or more established, researched based theoretical
approaches and combines them to draw from the best of each according to
each client’s needs. For example, a counselor might combine person-
centered therapy with CBT to help clients overcome obstacles. This mental
health professional would select strategies and ideas from these two
theories when working with all clients, and the specific tools used would
vary according to an individual client’s needs.
Technical (think “technique”) eclecticism means that a therapist, rather
than adhering to a small number of therapeutic approaches, selects
techniques from a wide variety of different therapies depending on what is
needed. The clinician selects a technique that is shown by research to help a
particular issue. Often, therapists use Systematic Treatment Selection
(STS), a research-based system developed by Larry Beutler and John
Clarkin consisting of 18 principles and guidelines to help determine the
very best techniques for a given client and problem.
Common factors eclectic therapy is based more on core elements essential
to healing than on specific tools and techniques. Therapists gravitate
toward the underlying belief systems of therapies, such as unconditional
positive regard, hope, trust, and empathy as well as driving factors like
correcting emotions, changing beliefs, or providing honest feedback to
clients to help them see themselves more clearly.
Assimilative integration is an approach in which a solid grounding in one
theoretical approach is accompanied by a willingness to incorporate
techniques from other therapeutic approaches. In technical eclecticism, the
same diversity of techniques is displayed, but without a binding theoretical
understanding.
Assimilative integration is particularly useful in that theory can help in
understanding the needs of the patient, and then several different
approaches to technique can help tailor-make a treatment that fits with that
particular understanding.

Example : Eclectic Therapy for Anxiety

After learning more about the client and their experience with anxiety, an
eclectic therapist would create a plan that draws from acceptance and
commitment therapy (ACT), cognitive behavioral therapy, and positive
psychology.
 Techniques from ACT, such as acceptance and mindfulness,
would help a client stop struggling against anxiety and begin
living fully in their present moment rather than stuck in worries
about the past or future.
The therapist would select specific CBT techniques like learning
about automatic negative thoughts and thought stopping, to help
clients change unhealthy thinking that is contributing to anxiety.
As treatment progresses, the therapist would eventually add
techniques from positive psychology such as identifying and
using character strengths to help the client increase self-
confidence.

Pros of an Eclectic Approach

It’s flexible to accommodate different clients’ needs rather than

a one-size-fits all approach to therapy
It is useful for multiple and complex problems (usually, people
see a therapist for more than one issue or a single issue that is
multifaceted)
The techniques used are research-based and shown to be
effective
The therapy is adapted to the client rather than the client having
to fit into a set model

Cons of an Eclectic Approach

It can feel unpredictable or confusing

It might seem like the therapist is using a trial-and-error
approach
There isn’t a clear, obvious, or predictable structure.
Integrative approach
Integrative therapy incorporates multiple schools of therapy into one
approach. Other therapies are typically based on a single model, and
therapists who work within the same model have similar goals and
approaches. Integrative therapy, on the other hand, allows therapists to
work in a more flexible manner, tailoring their goals and approach to each
client. In most cases, this means a combination of psychodynamic,
cognitive behavioral, and humanistic therapies. needs. Integrative therapy
is effective in helping people to manage a range of concerns, including
anxiety, depression, and personality disorders.
It works based on evidence-based research. It pays particular attention to
establishing a positive client/therapist relationship, and research shows that
is important for successful treatment.
4 Key Concepts of Integrative Therapy
Integrated therapy is based on these four concepts:

1. There is no single theory that explains all human

behavior: Integrative therapists may refer to more than one
theory when they think about their clients and how their
symptoms began.
2. Different approaches may work for different clients: People
are unique by nature. What works for one person may not work
for another.
3. The therapist should tailor their approach to the client: For
therapy to be effective, therapists need to take into account their
 client’s specific problems and history and use this information to
guide their approach.
4. The relationship between a client and therapist is an
important component of successful therapy: The therapeutic
relationship can be a powerful vehicle of change. Components of
a positive therapeutic relationship include empathy, congruence,
and unconditional positive regard.

Syncretism v/s Eclecticism

Eclectic therapists generally do not subscribe to common set of principles
since eclectic approach is based on differences rather than similarities.
Hence there are several eclectic approaches. Each eclectic therapists
functions based on specific training received, experience, probably with
bias and on case by case basis with no common set of principles.
Syncretism
There is a very thin line between integration or eclecticism and syncretism.
In words of Norcross & Tomcho. “Some self- designated eclectic or
integrative counsellor’s are, in actuality, Practicing syncretism : an
arbitrary and unsystematic blending of concepts of two or more of the
400 plus schools of psychotherapy. Their pluralistic intentions are to be
commended, but their haphazard hybrids are an outgrowth of pet
techniques and inadequate training”.
The uncertainty of eclectic psychotherapy is primarily due to two factors.
Firstly, the theory has been largely ignored in the Eclectic stance and
secondly, in the attempt to include as many as possible diverse methods or
techniques, there is little concern for their compatibility or orderly
integration .Under this condition, eclecticism takes the form of
syncretism. Therefore, Syncretism can be described as the combination of
different and Often contradictory beliefs, while merging practices of
diverse schools of thought.

UNIT 5: RESEARCH IN PSYCHOTHERAPY

#Research in psychotherapy

Research in psychotherapy is still burdened by many

handicaps. Yet the literature is replete with studies
flaunting impressive statistics that "prove “the
superiority of one brand of psychotherapy over others
or downgrade all forms of psychotherapy as worthless
or limited at best.
And still do not possess a model of psychotherapy
research that we can consider uniquely applicable to the
special problems .
Research in psychotherapy to this date has had
surprisingly little impact on contemporary clinical
practice.

#Effectiveness of psychotherapy
Moreover, it appears that when psychotherapy and
medications are withdrawn (ie, the psychotherapy is
terminated or the course of medication is finished),
the effects of psychotherapy are longer lasting in
that, at various times following the end of treatment,
a greater number of clients who have been on
medication relapse. It appears that psychotherapy
 provides clients with skills with coping with the
world and with their disorder.
Moreover, clients who have received previous
courses of medication become resistant t additional
course of medication, whereas they do not become
resistant with additional course of cognitive therapy.
As a general class of healing practices,
psychotherapy is remarkable effective. In clinical
trials, psychotherapy results in benefits that far
exceed the benefits of those who do not get
psychotherapy.
Indeed, psychotherapy is more effective than many
commonly used evidence- based medical practices,
some of which have side effect sand are quite
expensive .
In addition, psychotherapy is as effective as
medications for prevalent mental disorders, is longer
lasting, and is less resistant to additional courses.

#Measuring therapeutic improvement

Present-day outcome studies shows impressive

statistics about the effectiveness of psychotherapy
that contradict published negative reports .
General procedures for the measurement of outcome
have been detailed by a number of authorities,
including Waskow and Parloff.
 The primary concern is identifying the specific
variables that are significant to measure and that
give us reliable and valid data.
Another concern also are the research designs that
can best provide answers to our questions about
outcome.
The instruments that are used for the gauging of
outcome must be selected carefully, recognizing that
no one instrument is suitable for different patient
populations and for varying forms of psychotherapy.
Among the measures in use today are: self-reporting
that deals with the patient's daily functioning, broad
anamnestic materials in the popular Minnesota
Multiphasic Personality Interview ;data from family
and friends; a "Community Adjustment Scale;
therapist assessment scales ;material from
community agencies or members
problems exist in any attempt to measure the results
of psychotherapy or to verify its empirical
propositions:
problems in applying scientific method to evaluation
studies:

1. There is disagreement as to which observable phenomena

are worthy of observation.
2. The data available for study are difficult to manipulate
and control, interfering with conditions ripe for experiment.

3. It is cumbersome to qualify the quantitative data of

psychotherapy due to the complexity of the variables
 involved.

4. Available units of measurement are ill-defined,

interfering with comparisons and with the synthetization of
similarities and differences into a homogeneous unity.
5. Theoretic prejudices and personal biases make for a loss
of objectivity and an interference with the ability to utilize
imagination in hypothetic structuring

6. The absence of an accepted conceptual framework that

can act as a basis for communication obstructs the
formulation of inferential judgments regarding order in the
observed phenomena blocking the deduction of valid
analogies justified by the available facts, and hindering the
exploration of causal connections between antecedents and
Consequences.

7. The reliability of our results is distorted by a variety of

other difficulties that are related to special problems of the
therapist, the resistances of the patient, the amorphous status
of diagnosis, the prejudiced selection of the sample, the
involvements of outside judges, coders ,and raters, the
inability to employ adequate controls, the interferences of
adventitious non-specific changes, and certain complexes
inherent in the psychotherapeutic process itself.
#Efficiancy and efficacy of therapy

The effectiveness of psychotherapy for disorders are by

conducting studies
 The efficacy of treatment is determined by a clinical trials
in which many variables are carefully controlled to the
efficacy of treatment is determined by a clinical trials in
which many variables are carefully controlled to
demonstrate that the relationship between the treatment
and outcome add relatively unambiguous
efficacy studies emphasise the internal validity of
experimental design through a variety of means
These and other strategies are used to enhance the ability
of investigator to make causal inference based on findings.

Effectiveness study

conducted in natural clinical settings when the

interventions is implemented without same level of
internal validity that is present in clinical trials
it emphasis external validity of experimental design.
Treatment dose not controlled and therapist other
adherence treatment Guidelines neither highly specified
nor monitored.
therapist tend to be those working in clinical settings
and may or may not receive.
Seligman conducted an efficacy study and wrong
method for empirically validating psychotherapy as it is
done
Effectiveness studies are needed to determine what
treatment work on field.
Effectiveness studies do not require relaxation of
methodological rigour instead it is done by steps like
broadening sample size.
positives of efficacy studies

Randomization is homogeneous
Specification of treatment procedures
Method for assuring fidelity of treatment delivery
Blind rating
Rigorous strong control group
Inclusion- exclusion criteria
Operationally defined outcomes
Able to draw strong causal inference including the
attribution of treatment effects to treatment rather
than a variety of other variables

Positives of effectiveness studies

Use of typical practitioners and settings

variable amount of treatment
Mixtures of treatment
inclusion of patients with multiple disorders
measures of improvements other than symptom
relief
Careful assessment of characteristics of settings
Measures of representativeness of samples
Measure of actual treatment received both type
and amount
Assessments of while treatments were not
received; cause of treatment and sometimes the
use of controls.

MODULE 2