CHAPTER 5: THERAPEUTIC APPROACHES

1) Describe the nature of psychotherapy.

• Psychotherapy refers to a voluntary relationship between the client and the
therapist.
• Purpose of the relationship is to help the client solve the psychological
problems being faced by her/him.
• Psychotherapies aim at
o changing the maladaptive behaviours
o decreasing the sense of personal distress, and
o helping the client to adapt better to her/his environment.
• The goals of psychotherapy are:
o Reinforcing client’s resolve for betterment.
o Lessening emotional pressure.
o Unfolding the potential for positive growth.
o Modifying habits.
o Changing thinking patterns.
o Increasing self-awareness.
o Improving interpersonal relations and communication
o Facilitating decision-making
o Becoming aware of one’s choices in life
o Relating to one’s social environment in a more creative and self-
aware manner.

2) Discuss the characteristics of psychotherapeutic approaches.

All psychotherapeutic approaches have the following characteristics:
• There is systematic application of principles underlying the different
theories of therapy.
• Persons who have received practical training under expert supervision can
practice psychotherapy.
• The therapeutic situation involves a therapist and a client who seeks
and receives help for her/his emotional problems.
• The interaction of the therapist and the client results in the formation of
the therapeutic relationship.

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3) What do you mean by therapeutic alliance?
Therapeutic alliance is the special relationship between the therapist and the
client. The client needs to trust the therapist and the therapist should have
unconditional positive regard and empathy for the client. This relationship is a
professional relationship and the therapist must maintain confidentiality.

4) What are the two major components of a therapeutic alliance?

The special relationship between the client and the therapist is known as the
therapeutic alliance. The two major components of a therapeutic alliance are –
• Contractual nature of the relationship in which the therapist and client
enters into a partnership aiming at helping the client overcome his/her
problems.
• Limited duration of the therapy as the alliance lasts until the client becomes
able to deal with his/her problems and take control of one’s life.

5) Discuss the unique properties of a therapeutic relationship.

Therapeutic relationship has several unique properties.
• Trust and Confidence: The high level of trust enables the client to unburden
himself/herself to the therapist and confide his/her psychological and
personal problems to the latter.
• Unconditional Positive Regard: This indicates that the positive warmth of
the therapist is not dependent on what the client reveals or does in the
therapy sessions.
• Empathy: Refers to understanding things from the other person’s
perspective, i.e., putting oneself in the other person’s shoes.
• Confidential: 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.
• Professional Relationship: Professional boundaries are intended to set
limits, which, if crossed, will constitute unprofessional behaviour and
misuse of power.

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6) What are the different types of psychotherapy? On what basis are they
classified?
Psychotherapies may be of different types: psychodynamic, behaviour-
cognitive, and humanistic-existential therapies.
The classification of psychotherapies is based on the following parameters:
1. What is the cause, which has led to the problem?
• Psychodynamic therapy: Intrapsychic conflicts are the source
of psychological problems.
• Behaviour therapy: Psychological problems arise due to faulty learning
of behaviours and cognitions.
• Existential therapy: The questions about the meaning of one’s life and
existence are the cause of psychological problems.
2. How did the cause come into existence?
• Psychodynamic therapy: Unfulfilled desires of childhood and
unresolved childhood fears lead to intrapsychic conflicts.
• Behaviour therapy: Faulty conditioning patterns lead to faulty learning
of behaviours and thoughts.
• Existential therapy: Current feelings of loneliness, alienation, sense of
futility of one’s existence, etc. causes psychological problems.
3. 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
from the unconscious.
• Behaviour therapy: Identifies the faulty conditioning patterns and sets
up alternate behavioural contingencies to improve behaviour.
• Existential therapy: Provides a therapeutic environment which is
positive, accepting, and non-judgmental.
4. What is the nature of the therapeutic relationship between the client and
the therapist?
• Psychodynamic therapy: The therapist understands the client’s
intrapsychic conflicts better than the client and the therapist interprets
the thoughts and feelings of the client to her/him.
• Behaviour therapy: The therapist identifies the faulty behaviour and
thought patterns of the client and suggests the correct behaviour and
thought patterns, which would be adaptive for the client.

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 • Existential therapy: The therapist acts a facilitator and provides a
warm, empathic relationship in which the client feels secure to explore
the nature and causes of her/his problems by herself/himself.
5. What is the chief benefit to the client?
• Psychodynamic therapy: Emotional insight is achieved when the client
understands her/his conflicts intellectually and is able to accept the same
emotionally.
• Behaviour therapy: Changing faulty behaviour and thought patterns
to adaptive ones ensures reduction of distress and removal of symptoms.
• Existential therapy: Personal growth is the process of gaining
increasing understanding of oneself, and one’s aspirations, emotions
and motives.
6. What is the duration of treatment?
• Psychodynamic therapy: The duration of classical psychoanalysis may
continue for several years. However, several recent versions of
psychodynamic therapies are completed in 10–15 sessions.
• Behaviour therapy: Durations are shorter and are completed in a few
months.
• Existential therapy: Durations are shorter and are completed in a few
months.

7) What do you mean by clinical formulation? Discuss the steps in the

formulation of a client’s problem.
The process of psychotherapy begins by formulating the client’s problem.
Clinical formulation refers to formulating the problem of the client in the
therapeutic model being used for the treatment.
Steps involved in the formulation of a client’s problem are:
 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 targeted for treatment in psychotherapy:
The theoretical formulation clearly identifies the problem areas to be
targeted for therapy. Thus, if a client seeks help for inability to hold a job
and reports inability to face superiors, the clinical formulation would state it
as lack of assertiveness skills and anxiety. The target areas would be
inability to be assertive and high anxiety.

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  Choice of techniques for treatment: The choice of techniques for treatment
depends on the therapeutic system in which the therapist has been trained.
The clinical formulation is an ongoing process. Formulations may require
reformulations as clinical insights are gained in the process of therapy.

8) What do you mean by behaviour therapy? Discuss the method of treatment

conducted to find malfunctioning behaviours in behaviour therapy.
• Behaviour therapy is a therapy based on the principles of learning, that
postulates that psychological distress arises because of faulty behaviour
patterns.
• The therapy involves conducting a behavioural analysis to identify the –
o Malfunctioning behaviours – Behaviours which cause distress to the
client.
o Antecedent factors – Causes which predispose the person to indulge in
that behaviour
o Maintaining factors – Behaviours that maintain or continue faulty
learning and lead to the persistence of the faulty behaviour.
• Once the faulty behaviours which cause the 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.
o Antecedent operation involves controlling behaviour by changing
something that precedes such behaviour.
o Consequent operation involves increasing or decreasing the reinforcing
value of a particular consequence.

9) Discuss the various techniques used in behaviour therapy.

The principle of behaviour techniques are to reduce the arousal level of the
client and alter behaviour through classical conditioning, operant conditioning
or observational learning.
The various techniques used are:
• Negative Reinforcement: Involves responses that lead individuals to get rid
of painful stimuli or avoid and escape from them. For example, one learns
to wear sunscreen to avoid sun burn.

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• Aversive conditioning: Refers to repeated association of undesired
response with an aversive consequence. For example, when alcohol is
paired with an emetic drug, nausea or vomiting is induced. Repeated
pairings of alcohol and nausea makes alcohol become aversive and the
person will eventually give up alcohol.
• Positive Reinforcement: Refers to the introduction of a pleasant stimulus
after a desirable behavior occurs. This is given to increase the occurrence of
adaptive behaviour. For example, Mother prepares the child’s favourite
dish whenever he does homework at the appointed time.

• Token Economy: People 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 person or a
treat for the child.

• Differential Reinforcement: Unwanted behaviour can be reduced and

wanted behaviour can be increased simultaneously through differential
reinforcement. Either, the wanted behaviour can be positively reinforced
and the unwanted behaviour be negatively reinforced, or the wanted
behaviour can be positively reinforced and the unwanted behaviour be
ignored. For example: Consider the case of a girl who sulks and cries when
she is not taken to the cinema when she asks. In order to increase the
wanted behaviour of politely asking to be taken to the cinema, the parent is
instructed to take her to the cinema only if she does not cry and sulk. Also,
they are instructed to ignore the girl when she cries and sulks.
• Systematic desensitization: It is a technique introduced by Wolpe for
treating phobias or irrational fears. The client is interviewed to elicit fear-
provoking situations and together with the client, the therapist prepares a
hierarchy of anxiety-provoking stimuli with the least anxiety-provoking
stimuli at the bottom of the hierarchy. The therapist initially gives relaxation
training to the client. When the client becomes relaxed, he is asked to think
about the least anxiety-provoking situation. Over sessions, the client is able
to imagine more severe fear-provoking situations while maintaining
the relaxation. The client gets systematically desensitized to the fear. This
technique is based on the principle of reciprocal inhibition, which states that
when two mutually opposing forces occur at the same time, the stronger

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 force inhibits the weaker force (i.e., relaxation overpowers the fear
response).
• Modelling: It is 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 is a part of modelling
technique in which the client learns by observing others through the process
of rewarding small changes in the behaviour.

10) Write a short note on Rational Emotive Therapy (RET).

• Rational Emotive Therapy is a form of cognitive therapy which is
formulated by Albert Ellis.
• The central thesis of this therapy is that irrational beliefs mediate between
the antecedent events and their consequences.
• The first step in RET is the antecedent belief-consequence (ABC) analysis.
This involves identifying the –
o Antecedent Events – events that cause the psychological distress
o Irrational beliefs – beliefs which are distorting the present reality and
are characterised by thoughts with ‘musts’ and ‘shoulds’, i.e., things
‘must’ and ‘should’ be in a particular manner.
o Consequence – This distorted perception of the antecedent event due to
the irrational belief leads to the consequence, i.e. negative emotions and
behaviours (e.g. depression)
• The irrational beliefs are assessed through questionnaires and interviews. In
this process, the irrational beliefs are proven false by the therapist through a
process of non-directive questioning (gentle, without probing). The
questions make the client to think deeper into his/her assumptions about life
and problems. Gradually the client is able to replace the irrational
belief system with a rational belief system and there is a reduction
in psychological distress.

11) Explain with the help of an example how cognitive distortions take place.
• The basic assumption of Aaron Beck’s cognitive therapy is that negative
thinking, irrational beliefs and faulty generalizations lead to psychological
distress.
• Childhood experiences provided by the family and society develop core
schemas or systems, which include beliefs and action patterns in the

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 individual. For example: 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, various critical incidents may validate these
thoughts and trigger the core schema leading to the development of negative
automatic thoughts (“Nobody loves me”, “I am ugly”, etc.).
• Such negative automatic thoughts are characterized by cognitive distortions
(ways of thinking which are general in nature but which distort the reality in
a negative manner).
• These patterns of thought are called dysfunctional cognitive structures,
which lead to errors of cognition about the social reality.
• Repeated occurrence of these thoughts leads to the development of feelings
of anxiety and depression.
• The treatment involves cognitive restructuring, whereby the therapist
questions the client’s beliefs and thoughts in a gentle, non-threatening
manner. The questions make the client think in a direction opposite to that
of the negative automatic thoughts and gain insight into the nature of his
dysfunctional schemas. This in turn, reduces anxiety and depression.

12) What do you mean by cognitive behaviour therapy? What kind of

problems is CBT best suited for?
• Cognitive Behaviour therapy is a short and efficacious treatment.
• According to CBT, the client’s distress has its origins in the
biological, psychological and social realms. CBT addresses the biological
aspects through relaxation procedures, the psychological ones through
behaviour therapy and cognitive therapy techniques, and the social aspects
with environmental manipulations.
• This biopsychosocial approach makes CBT a comprehensive technique
which is easy to use, applicable to a variety of disorders, and has proven
efficacy.
• CBT can be suited for a wide range of psychological disorders such as
anxiety, depression, panic attacks and borderline personality.

13) Which therapy encourages the client to seek personal growth and actualize
their potential? Write about the therapies which are based on this
principle.
• The humanistic-existential therapy encourages the client to seek personal
growth and actualize their potential.
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• Therapies which are based on this principle are:
➢ Existential Therapy:
o Logotherapy is a form of existential therapy propounded by Victor
Frankl.
o The basic assumption is that a person’s desire of finding the spiritual
truth of one’s existence is the source of motivation. Finding meaning
of one’s existence even in life-threatening circumstances is the
process of meaning making.
o Neurotic anxieties arise when the problems of life are attached to the
physical, psychological or spiritual aspects of one’s existence.
Spiritual anxiety leads to meaninglessness and hence it is called
existential anxiety, i.e., neurotic anxiety of spiritual origin.
o The goal of therapy is to facilitate the client to find the meaning of
his/her being. The therapist is open and shares his feelings, values
and his own existence with the client. The emphasis is on here and
now and transference is actively discouraged.
➢ Client-Centred Therapy:
o Client-centred therapy was given by Carl Rogers.
o He emphasized freedom and choice as the core of one’s being.
o The therapy provides an unconditional positive regard to ensure that
the client feels secure to confide to the therapist and thereby reconnect
with her/his disintegrated feelings. The therapist reflects the feelings
of the client in a non-judgmental manner by rephrasing the statements
of the client. This process of reflection helps the client to become
integrated.
o This therapy helps a client to become her/his real self with
the therapist working as a facilitator.
➢ Gestalt Therapy:
o This therapy was given by Freiderick (Fritz) Perls and Laura Perls.
o This goal of this therapy is to increase the client’s self-awareness and
self-acceptance.
o The therapist encourages the client to act out fantasies about feelings
and conflicts, whereby the client is able to understand his emotions
that are being blocked out from the awareness.
o This therapy can also be used in group settings.

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14) What are the factors that contribute to healing in psychotherapy?
Psychotherapy is a treatment of psychological distress. There are several factors
which contribute to the healing process. Some of these factors are:
• Techniques adopted by the therapist and the implementation of the
same with the client.
• The therapeutic alliance, which is formed between the therapist and
the client, has healing properties because of the regular availability of
the therapist and the empathy provided by the therapist.
• Catharsis is the process of emotional unburdening that may occur at the
outset of therapy while the client is being interviewed in the initial sessions
to understand the nature of the problem.
• Non-specific factors associated with psychotherapy:
o Patient Variables: Includes motivation for change, expectation
of improvement due to the treatment, etc.
o Therapist Variables: Includes positive nature, absence of unresolved
emotional conflicts, presence of good mental health, etc.

15) Enumerate some of the alternative therapies.

Alternative therapies are alternative treatment possibilities to the conventional
drug treatment or psychotherapy. There are many alternative therapies such as
yoga, meditation, acupuncture, herbal remedies, etc.
• Yoga is an ancient Indian technique detailed in the Ashtanga Yoga of
Patanjali’s Yoga Sutras. It refers to asanas (body posture) and pranayama
(breathing practice).
• Meditation refers to the practice of focusing attention on breath or on an
object or thought or a mantra.
• Vipassana meditation (mindfulness-based meditation): There is no fixed
object or thought to hold the attention. The person passively observes the
various bodily sensations and thoughts that are passing through in her or his
awareness. May be used to prevent repeated episodes of depression.
• Sudarshana Kriya Yoga (SKY): Involves rapid breathing techniques to
induce hyperventilation. It is found to be a beneficial, low-risk, low-cost
method to the treatment of stress, anxiety, post-traumatic stress disorder
(PTSD), depression, stress-related medical illnesses, substance abuse, and
rehabilitation of criminal offenders.

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 • Kundalini Yoga: Combines pranayama with chanting of mantras. It
has been found to be effective in treatment of mental disorders, especially
obsessive-compulsive disorder.

16) What are the techniques used in the rehabilitation of the mentally ill?
The treatment of psychological disorders has two components – reduction
of symptoms and improving the level of functioning or quality of life. The aim
of rehabilitation is to empower the patient to become a productive member of
society. In rehabilitation, the patients are given:
• Occupational therapy: Focus on adapting the environment, modifying the
task, teaching the skill, and educating the client/family in order to increase
participation in and performance of daily activities, particularly those that
are meaningful to the client. Patients are taught skills such as
candle making, paper bag making and weaving to help them to form a work
discipline.
• Social skills training: Helps people improve their social skills so they can
become socially competent. Helps to develop interpersonal skills through
role play, imitation and instruction.
• Cognitive retraining: Given to improve the basic cognitive functions
of attention, memory and executive functions.
• Vocational Training: Given after the patient becomes self-sufficient
wherein, he/she is helped to gain skills necessary to undertake productive
employment. The primary goal is to assist individuals with disabilities to
regain their independence through employment or some form of meaningful
activity and reintegration into society.

17) How would a social learning theorist and a psychoanalyst account for a
phobic fear of lizards?
• According to social learning theory, phobic fear of lizards is a result of
faulty learning which may start early in life. This is often conditioned by
associating the fear with a personal experience or observing and modelling
the experience of others. This phobia can be treated using the technique of
systematic desensitization. The therapist, along with the client, prepares a
hierarchy of fear-evoking stimuli and tries to counter-condition the fear
response with the relaxation response. As a result, the client gets
systematically desensitized to the fear.

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 • A psychoanalytical account for the same could involve attributing the cause
of phobia to intrapsychic conflicts which may have resulted from unresolved
repressed traumatic experiences with lizards. The phobia can be treated
using the techniques of free association and dream analysis or using
modalities of psychoanalytic approach. Through these methods, the
individual may be given an insight about the reason for fear and the various
disturbed emotions associated with it.

18) Discuss some ethical standards that need to be practiced by professional

psychotherapists.
Some of the ethical standards that need to be practiced by professional
psychotherapists are:
• Informed consent needs to be taken.
• Confidentiality of the client should be maintained.
• The goal of the therapist should be alleviating personal distress
and suffering
• Integrity of the practitioner-client relationship is important.
• Respect for human rights and dignity.
• Professional competence and skills are essential.

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