CHAPTER- 5

THERAPEUTIC APPROACHES
INTRODUCTION

• Refers to a variety of treatments that aim to help a person identify and change troubling emotions,
thoughts, and behaviors
• Purpose: to help the client to solve the psychological problems being faced by her or him.
• Aim: changing the maladaptive behaviours, decreasing the sense of personal distress, and helping
the client to adapt better to her/his environment
NATURE
Characteristics :
• there is systematic application of principles underlying the different theories of therapy
• Expertise is required to practice psychotherapy
• the therapeutic situation involves a therapist and a client who seeks and receives help for her/his
emotional problems
• the interaction of these two persons — the therapist and the client — results in the
consolidation/formation of the therapeutic relationship
Goals:
• Reinforcing client’s resolve for betterment.
• Lessening emotional pressure.
• Unfolding the potential for positive growth.
• Modifying habits.
• Changing thinking patterns.
• Increasing self-awareness.
• Improving interpersonal relations and communication.
• Facilitating decision-making.
• Becoming aware of one’s choices in life.
• Relating to one’s social environment in a more creative and self-aware manner.
THERAPEUTIC RELATIONSHIP/ALLIANCE
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.

• It has 2 components:
a) contractual nature: two willing individuals, the client and the therapist, enter into a
partnership which aims at helping the client overcome her/his problems.
b) limited duration: alliance lasts until the client becomes able to deal with her/his problems
and take control of her/his life
• Properties:
a) It is a trusting and confiding relationship: This helps the client to open up with the therapist
and share his/her psychological problems.
b) The therapist must be accepting, empathic, genuine and warm to the client. He/she must be
non-judgemental towards client and show positive feelings towards the client.
 Sympathy: one has compassion and pity towards the suffering of another
Intellectual understanding: the person is unable to feel like the other person and does not feel sympathy
either
Empathy: 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.

c) Therapist must provide unconditional positive regard i.e. 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.
d) the therapist must keep strict confidentiality of the experiences, events, feelings or
thoughts disclosed by the client.
e) Professional relationship must be maintained
TYPES OF THERAPIES/CLASSIFICATION OF THERAPIES
Psychotherapies may be classified into three broad groups, viz. the psychodynamic(1st force), behaviour(2nd
force), and existential psychotherapies(3rd force).

STEPS IN FORMULATION OF A CLIENT’S PROBLEM/CLINICAL FORMULATION

Clinical formulation refers to formulating the problem of the client in the therapeutic model being used for
the treatment. The clinical formulation is an ongoing process.
 1. Understanding of the problem : The therapist is able to understand the full implications of the
distress being experienced by the client.
2. Identification of the areas to be targeted for treatment in psychotherapy : The theoretical
formulation clearly identifies the problem areas to be targeted for therapy.
3. Choice of techniques for treatment : The choice of techniques for treatment depends on the
therapeutic system in which the therapist has been trained. However, even within this broad
domain, the choice of techniques, timing of the techniques, and expectations of outcome of the
therapy depend upon the clinical formulation.
BEHAVIOUR THERAPY
Introduction:
Behaviour therapies postulate that psychological distress arises because of faulty behaviour patterns or
thought patterns. It is, therefore, focused on the behaviour and thoughts of the client in the present. The
past is relevant only to the extent of understanding the origins of the faulty behaviour and thought patterns
Method of treatment

• Behavioural analysis is conducted to find malfunctioning behaviours, the antecedents of faulty

learning, and the factors that maintain or continue faulty learning
• Malfunctioning behaviours are those behaviours which cause distress to the client.
• Antecedent factors are those causes which predispose the person to indulge in that behaviour.
• Maintaining factors are those factors which lead to the persistence of the faulty behaviour
• Once the faulty behaviours which cause distress, have been identified, treatment is started. Aim of
the treatment is to extinguish the faulty behaviours and substitute them with adaptive behaviour
patterns
• 2 kinds of operations are established:
a) Antecedent operations: control behaviour by changing something that precedes such a
behaviour
b) Consequence operations: provide reinforcement/reward when wanted behaviour is shown
• The change can be done by 2024-25 Chapter 5 • Therapeutic Approaches 95 increasing or
decreasing the reinforcing value of a particular consequence. This is called establishing operation
Techniques
1. Reinforcements: any stimulus that repeats the occurrence of a response. They are of two types:
Negative Positive
• When an unpleasant stimulus is taken • When a pleasant stimulus is provided
away to reinforce behavior to reinforce a behaviour.
• It creates avoidance responses • It creates approach responses
• For e.g. wearing sweaters to avoid • For e.g. receiving money/chocolates
cold weather for helping mother at home.

2. Aversive conditioning/aversive learning/aversive therapy: refers to repeated association of undesired

response with an aversive consequence. For example, an alcoholic is given a mild electric shock and
asked to smell the alcohol. With repeated pairings the smell of alcohol is aversive as the pain of the
shock is associated with it and the person will give up alcohol.
3. Token economy: Persons with behavioural problems can be given a token as a reward every time a
wanted behaviour occurs. The tokens are collected and exchanged for a reward such as an outing for
the patient or a treat for the child.
4. Differential reinforcements: Unwanted behaviour can be reduced (negative reinforcement) and wanted
behaviour (positive reinforcement) can be increased simultaneously. The other method is to positively
reinforce the wanted behaviour and ignore the unwanted behaviour—less painful and equally effective.
5. Systematic desensitisation:
a) a technique introduced by Wolpe for treating phobias or irrational fears
b) it is used to treat phobias.
c) the therapist prepares a hierarchy of anxiety-provoking stimuli with the least anxiety-provoking
stimuli at the bottom of the hierarchy
d) The therapist relaxes the client and asks the client to think about the least anxiety-provoking
situation and then is asked to relax and to stop thinking of the fearful situation if the slightest
tension is felt.
e) Various relaxation techniques are taught to the client. According to behaviour therapy, anxiety
can act as an antecedent factor. Therefore, reduction in anxiety would decrease unwanted
behaviour. Relaxation methods/procedures like progressive muscular relaxation(client is taught
to contract individual muscle groups in order to give the awareness of tenseness or muscular
tension. After that, the client is asked to let go the tension) and meditation.
f) Over sessions, the client is able to imagine more severe fear -provoking situations while
maintaining the relaxation. The client gets systematically desensitised to the fear.
g) Operates on the principle of reciprocal inhibition—the presence of two mutually opposing
forces (relaxation response vs. anxiety-provoking scene) at the same time, inhibits the weaker
force. The client is able to tolerate progressively greater levels of anxiety because of his/her
relaxed state.
6. Modelling/vicarious learning: learning by observing others, is used and through a process of rewarding
small changes in the behaviour, the client gradually learns to acquire the behaviour of the model.
COGNITIVE THERAPY
According to these therapists, the cause of psychological distress lies in our irrational thoughts and beliefs.
Techniques used:
1. REBT(rational emotive behaviour therapy)/RET(rational emotive therapy)/ABC Model
• The first step to identify or do the ABC analysis
➢ A= antecedent/activating event
➢ B= irrational belief
➢ C= emotional consequences
• Antecedent events: cause of the distress are noted
• Irrational beliefs: beliefs that distort reality. These beliefs are characterised by thoughts with
‘musts’ and ‘shoulds’, i.e. things ‘must’ and ‘should’ be in a particular manner.
• Emotional consequences: these beliefs causes negative emotions like depression and anxiety.
• Non-directive questioning is used to refute these irrational beliefs. Non direct questions are
gentle, without threat, and are not direct. These questions helps the client to gain insights and
gradually change irrational beliefs by changing their philosophy of life. For e.g. how did you act
after the event, what are the consequences of your belief, how would different beliefs lead to
different outcomes etc.
• Change in such beliefs reduces psychological distress.
2. Aaron Beck’s Cognitive Therapy:
• states that childhood experiences provided by the family and society develop core schemas or
systems. Schemas refer to fundamental beliefs about the world, oneself, and others that are
 deeply ingrained and difficult to change without intervention
For e.g. a client, who was neglected by the parents as a child, develops the core schema of “I am
not wanted”. During the course of life, a critical incident occurs in her/his life. S/ he is publicly
ridiculed by the teacher in school. This critical incident triggers the core schema of “I am not
wanted” leading to the development of negative automatic thoughts.
• Critical events in the individual’s life trigger the core, leading to the development of negative
automatic thoughts.
• Negative thoughts are persistent irrational thoughts characterised by cognitive distortions.
• These negative thoughts cause cognitive distortions. Cognitive distortions are ways of thinking
which distort the reality in a negative manner. These patterns of thought are called
dysfunctional cognitive structures/negative schemas.
• Repeated occurrence of these thoughts leads to the development of feelings of anxiety and
depression.
• The therapist uses questioning, which is gentle, non-threatening disputation of the client’s
beliefs and thoughts. Examples of such question would be, “Why should everyone love you?”,
“What does it mean to you to succeed?”, etc.
• The questions make the client think in a direction opposite to that of the negative automatic
thoughts whereby she/he gains insight into the nature of her/his dysfunctional schemas, and is
able to alter her/his cognitive structures.
COGNITIVE BEHAVIOUR THERAPY(CBT)

• CBT is a short and efficacious treatment for a wide range of psychological disorders such as anxiety,
depression, panic attacks, and borderline personality, etc
• CBT adopts a bio-psychosocial approach to the delineation of psychopathology. It combines
cognitive therapy with behavioural techniques.
• Hence, addressing the biological aspects through relaxation procedures, the psychological ones
through behaviour therapy and cognitive therapy techniques and the social ones with
environmental manipulations
HUMANISTIC-EXISTENTIAL THERAPY
Causes of psychological distress are:
➢ feelings of loneliness, alienation etc
➢ lack of meaning in life
➢ when needs of personal growth and self-actualisation are curbed by society
Self-actualisation is defined as an innate or inborn force that moves the person to become more complex,
balanced, and integrated. Integrated means a sense of whole, being a complete person.
The therapy creates a permissive, non-judgmental and accepting atmosphere in which the client’s
emotions can be freely expressed and the complexity, balance and integration could be achieved.
Assumption: client has the freedom and responsibility to control her/his own behaviour. The therapist is
merely a facilitator and guide. It is the client who is responsible for the success of therapy.
Aim: to expand the client’s awareness.
Healing occurs when the client is able to perceive the obstacles to self-actualisation in her/his life and is
able to remove them
Types:
1. Existential therapy/logotherapy:
 • Given by Victor Frankl
• The technique given by him is Logotherapy(logos is the Greek for soul). It means treatment of
the soul.
• It is process of finding meaning in even life-threatening circumstances. This is called meaning
making. People seek to find their spiritual truth for existence.
• He coined the term spiritual unconsciousness which is the storehouse of love, aesthetic
awareness and values of life
• Frankl emphasised the role of spiritual anxieties in leading to meaninglessness of life/existence
of an individual and hence it may be called an existential anxiety, i.e. neurotic anxiety of
spiritual origin.
• Goal of logotherapy: to help the patients to find meaning and responsibility in their life
irrespective of their life circumstances. This is achieved by putting emphasis on the unique
nature of the patient’s life and encourages them to find meaning in their life
• Things done in Logotherapy:
➢ the therapist is open and shares her/his feelings, values and his/her own existence with
the client
➢ The emphasis is on here and now.
➢ Transference is actively discouraged
➢ The goal is to facilitate the client to find the meaning of her/his being.
2. Client-centred therapy:
• Given by Carl Rogers
• Rogers brought into psychotherapy the concept of self, with freedom and choice as the core of
one’s being. This therapy helps a client to become her/his real self with the therapist working as
a facilitator.
• Methods used:
➢ Providing warmness: a warm relationship in which the client can reconnect with her/his
disintegrated feelings
➢ Empathy: means understanding the client’s experience as if it were her/his own.
Empathy sets up an emotional bond between the therapist and the client which makes it
easy for the client to open up
➢ Unconditional positive regard: It is the total acceptance of the client as s/he is. It
ensures that the client feels secure and can trust the therapist.
➢ Reflection and rephrasing: The therapist reflects the feelings of the client in a non-
judgmental manner. The reflection is achieved by rephrasing the statements of the
client, i.e. seeking simple clarifications to enhance the meaning of the client’s statements
3. Gestalt therapy:
• Given by Freiderick (Fritz) Perls and Laura Perls
• Goal: to increase an individual’s self-awareness and self-acceptance.
• The client is taught to recognise the bodily processes and the emotions that are being blocked
out from awareness.
• The therapist does this by encouraging the client to act out fantasies about feelings and
conflicts.
• This therapy can also be used in group settings.
FACTORS CONTRIBUTING TO HEALING IN PSYCHOLTHERAPY
1. Techniques adopted: techniques adopted by the therapist and the implementation of the same are a
 major factor. If the behavioural system and the CBT school are adopted to heal an anxious client, the
relaxation procedures and the cognitive restructuring largely contribute to the healing
2. Therapeutic alliance: it has healing properties, because of the regular availability of the therapist, and
the warmth and empathy provided by the therapist.
3. Catharsis: At the outset of therapy the patient/client unburdens the emotional problems being faced.
This process of emotional unburdening is known as catharsis, and it has healing properties.
4. Non-specific factors: factors not associated to the therapy are called non0specific factors. They are of 2
types:
❖ patient variables: Non-specific factors attributable to the client/patient are motivation for
change, expectation of improvement due to the treatment, etc
❖ therapist variables: Non-specific factors attributable to the therapist are positive nature,
absence of unresolved emotional conflicts, presence of good mental health, etc.
ETHICAL STANDARDS/ETHICS IN PSYCHOTHERAPY
o Informed consent needs to be taken.
o Confidentiality of the client should be maintained.
o Alleviating personal distress and suffering should be the goal of all attempts of the therapist.
o Integrity of the practitioner -client relationship is important.
o Respect for human rights and dignity.
o Professional competence and skills are essential.
ALTERNATIVE THERAPIES
• There are many alternative therapies such as yoga, meditation, acupuncture, herbal remedies and so on
• Yoga: Yoga is an ancient Indian technique detailed in the Ashtanga Yoga of Patanjali’s Yoga Sutras. It is
commonly referred today as the asanas or body posture component or to breathing practices or
pranayama, or to a combination of the two
• Meditation: Meditation refers to the practice of focusing attention on breath or on an object or thought
or a mantra. Here attention is focused
• Vipassana meditation/mindfulness: in this 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. Prevention of repeated episodes of depression may be helped by Vipassana. This
meditation help the patients to process emotional stimuli better
• Sudarshana Kriya Yoga (SKY):
➢ The rapid breathing techniques to induce hyperventilation is done in SKY.
➢ beneficial for the treatment of stress, anxiety, post-traumatic stress disorder (PTSD), depression,
stress-related medical illnesses, substance abuse, and rehabilitation of criminal offenders.
➢ Proper training by a skilled teacher and a 30-minute practice every day will maximise the
benefits
➢ It enhances well-being, mood, attention, mental focus, and stress tolerance
➢ Research conducted at the National Institute of Mental Health and Neurosciences (NIMHANS),
India, has shown that SKY reduces depression.
➢ alcoholic patients who practice SKY have reduced depression and stress levels
➢ Insomnia is treated with yoga. It reduces the time to go to sleep & improves the quality of sleep.
• Kundalini Yoga:
➢ The Institute for Nonlinear Science, University of California, San Diego, USA has found that
Kundalini Yoga is effective in the treatment of obsessive-compulsive disorder
➢ Kundalini Yoga combines pranayama or breathing techniques with chanting of mantras
REHABILITATION OF MENTALLY ILL

Treatment of psychological disorders have two components

• Reduction Of Symptoms
• Improvement In Quality Of Life

1. Above mentioned points are applicable in mild problems like Generalised Anxiety Disorders(GAD), but
in case of severe disorders like schizophrenia it is not applicable
2. Aim: to empower clients to become productive members of society
3. In rehabilitation, patients are given occupational therapy, social skills training, vocational therapy, and
cognitive training and they are described below:
• Occupational Therapy- Clients are taught work therapy and they are taught skills like weaving,
paper making, etc
• Social skills training- Clients are taught interpersonal skills like empathy, communication skills,
cooperation, etc
• Vocational therapy-employability skills are taught to clients in vocational therapy
• Cognitive training-patients are taught cognitive skills like decision-making, memory, etc