Therapeutic Approaches (Free Access)

Psychotherapy

Therapeutic relationship: The special relationship between the client and the therapist is known as the therapeutic relationship or alliance. It is neither a passing acquaintance, nor a permanent and lasting relationship.

Consists of elements of:

  • Trust
  • Cooperation
  • Help
  • Limited till the client is healthy
  • Empathic

Psychodynamics: A brief overview

  • There are four major schools of psychoanalytic theory:
    •       Classical Freudian
    •       Ego Psychology
    •       Object Relations
    •       Self Psychology
  • Psychodynamic theorists adhere to the notion of unconscious influences on conscious behaviours
  •  Psychodynamic theorists use introspective methods as a way to tap into internal thoughts and images
  • Sigmund Freud used the analogy of the iceberg to depict the complex interplay of conscious and unconscious forces
  • Freud believed that only 10% of personality is available to conscious awareness
  • Components of the Psyche
  • Freud’s theory outlines three mental components:
  • Id : Hedonistic
  • Ego: Realistic
  • Superego: Moralistic

The Id

  • Unconscious; operates according to the pleasure principle with no regard for moral principles
  • Primary process thinking achieves momentary satisfaction and wish fulfillment
  • Insight (catharsis) reduces tension
  • Freud termed the libido ‘eros’, and termed aggression ‘thanatos’

The Ego

  • Mostly conscious; operates according to the reality principle
  • Tries to align the urge of the id with reality using secondary process thinking
  • The ego considers the situation and past experience to engage in behaviour

The Superego

  • Mostly conscious; operates according to the perfection principle
  • Tries to uphold morality by a strict adherence to societal standards
  • Guilt and shame result from immoral behaviour for those having a strong superego
  • Freud developed a series of four psychosexual stages:
    • Oral Stage
    • Anal Stage
    • Phallic Stage
    • Genital Stage
  • Too little or too much gratification within each stage can result in fixations
  • Defense Mechanisms are the ego’s protective methods of reducing anxiety by unconsciously distorting reality
  • Repression – the basic defense mechanism that banishes anxiety-arousing thoughts, feelings, and memories from consciousness
  • Regression- defense mechanism in which an individual faced with anxiety retreats to a more infantile psychosexual stage, where some psychic energy remains fixated
  • Reaction Formation – defense mechanism by which the ego unconsciously switches unacceptable impulses into their opposites. People may express feelings that are the opposite of their anxiety-arousing unconscious feelings
  • Projection- defense mechanism by which people disguise their own threatening impulses by attributing them to others
  • Rationalization – defense mechanism that offers self-justifying explanations in place of the real, more threatening, unconscious reasons for one’s actions
  • Displacement- defense mechanism that shifts sexual or aggressive impulses toward a more acceptable or less threatening object or person. As when redirecting anger toward a safer outlet
  • Techniques
  • Free Association – is a method of exploring the unconscious
    • person relaxes and says whatever comes to mind, no matter how trivial or embarrassing
  • Dream analysis:  Dreams express unconscious issues
    • Manifest content:  the actual content of a dream
    • Latent content:  symbols that are disguised unconscious issues or motives
  • Resistance:  Therapist looks for evidence that the patient is avoiding an issue
  • Transference: Does the patient treat the therapist in ways that are similar to their parents?
  • Interpretation: Therapist provides analysis of the meaning of the thoughts, behaviors, and dreams of the patient.

Behavioural therapy

It is based on a scientific view of overt human behaviour and the usage of systematic and structured approach to counselling.

It assumes that the person is the result and creator of his/ her environment.

  • Basic Characteristics and Assumptions
  • Behavior therapy analyses a client’s current problems and its causes based on ideas of reinforcement, punishment, or conditioning and not a deep dive into the individuals history.
  • Behavior therapists look to the current environmental events that maintain problem behaviors and help clients produce behavior change by changing environmental events, through a process called behavioral analysis.
  • Clients assume an active role by engaging in activities that deal with their problems.
  • Clients are self-dependent and are asked to monitor their behaviors, learn and practice coping skills, carry out homework assignments.
  • Clients learn new and adaptive behaviors to replace old and maladaptive behaviors.
  • The focus is on a similar platform to the experimental method where assessment of overt behavior directly leads to identifying the problem, finding possible reasons, targeting those variables and evaluating change.
  • Behavioral treatment interventions are individually tailored to specific problems experienced by clients.

Goals

  • Problems must be clear, concrete, understood, and measurable and agreed on by the client and the counselor.
  • The aim is to modify or eliminate maladaptive behaviours and aid to acquire healthy, constructive ways of acting.
  • Continual assessment takes place throughout therapy to assess if identified goals are being met. Accordingly therapists and clients alter goals throughout the therapeutic process.

Therapist’s Function and Role

  • The ABC model – This model suggests that behavior (B) is influenced by some particular events that precede it, called antecedents (A), and by certain events that follow it called consequences (C).
  • Techniques used such as summarizing, reflection, clarification, and open-ended questioning.
  • Based on functional assessment, the therapist formulates initial treatment goals and designs and implements a treatment plan to accomplish these goals.
  • A large part of the therapist’s role is to teach concrete skills through the provision of instructions, modeling, and performance feedback.

Relationship between the Client and the Therapist

  • A therapeutic relationship, is important in the process of behavior change (Granvold & Wodarski, 1994).
  • Use of the client–therapist relationship in facilitating change is important
  • Most behavioral practitioners contend that factors such as warmth, empathy, authenticity and acceptance are necessary, but not sufficient, for behavior change to occur.
  • The client–therapist relationship is a foundation on which therapeutic strategies are built to help clients change in the direction they wish.
  • Behavior therapists assume that clients make progress primarily because of the specific behavioral techniques used rather than because of the relationship with the therapist.

APPLICATIONS

  • Flooding:  it’s a type of exposure therapy that involves either in vivo or imaginal exposure to anxiety-evoking stimuli for a prolonged period of time, without the occurrence of the feared consequence.
  • In vivo: In vivo flooding consists of intense and prolonged exposure to the actual anxiety-producing stimuli.
  • Imaginal: the client is exposed to the mental image of a frightening or anxiety-producing object or event and continues to experience the image of the event until the anxiety gradually diminishes.
    • Implosive therapy: An imaginal flooding approach in which the scenes are exaggerated rather than realistic and hypotheses are made about stimuli in the scene that may cause the fear or anxiety.
  • Systematic desensitization: a type of exposure therapy developed by Wolpe, in which, clients imagine successively more anxiety-arousing situations at the same time that they engage in a behavior that competes with anxiety. Gradually, or systematically, clients become less sensitive to the anxiety-arousing situation.
  • Covert sensitization: “Covert sensitization” associates an aversive stimulus with a behavior the client wishes to reduce or eliminate. This is done by imagining the target behavior followed by imagining an aversive consequence. It has been used to stop smoking, overeating, alcohol consumption, sexual deviations.
  • Token economy: is a system of behavior modification based on the systematic reinforcement of target behavior. The reinforcers are symbols or “tokens” that can be exchanged for other reinforcers. E.g. children may be provided tokens for good performance that can later be exchanged for valued materials.
  • Shaping: gradual movement from original to desired behaviour by reinforcing successive approximations of the desired behaviour. E.g. strengthening behaviour of playing on monkey bars by reinforcing each successive approximation towards it.
  • Pre mack: If high-probability behaviors (more desirable behaviors) are made contingent upon lower-probability behaviors (less desirable behaviors), then the lower-probability behaviors are more likely to occur. E.g. giving a child a banana (less desirable) to eat while he’s watching TV.(more desirable)
  • Aversive therapy works on this principle. E.g. mixing a substance that causes stomach ache in alcohol to decrease alcohol drinking behaviour.
  • Time out: client is separated from the opportunity to receive positive reinforcement.

Modeling is frequently used in situations that involve interpersonal communication.

Social Skills training:

Social skills training is a broad category that deals with an individual’s ability to interact effectively with others in various social situations; it is used to correct deficits clients have in interpersonal competencies.

It includes psychoeducation, modeling, reinforcement, behavioral rehearsal, role playing, and feedback.

Anger management training & assertion training are popular variations of social skills training.

Assertion training is for people who lack assertive skills

Self modification programs:

Psychologists share their knowledge so that “consumers” can increasingly lead self-directed lives and not be dependent on experts to deal with their problems.

Self-modification strategies include self-monitoring, self-reward, selfcontracting, stimulus control, and self-as-model. The basic idea of self-modification assessments and interventions is that change can be brought about by teaching people to use coping skills in problematic situations.

Cognitive Behavioural Therapy (Aaron Beck) (CBT)

Techniques of cognitive behavioral therapy

  • The therapist and the client work together as an investigative team.
  • Beck termed this form of therapeutic relationship collaborative empiricism.
  • The cognitive interventions used in CBT are designed first to identify and then to modify dysfunctional thinking at two main levels of cognitive processing—automatic thoughts and core beliefs schemas.
  • Identifying Automatic Thoughts
    • Using guided discovery 
      • Guided discovery involves gentle eliciting, exploring, and questioning of the patient’s thinking. Therapists ask Socratic-type questions that encourage the patient to expand his or her perspective and become actively involved in the learning process.
    • Recognizing mood shifts
      • A shift in mood during the therapy session can be an opportune time for the therapist to facilitate the identification of automatic thoughts. When the therapist observes that a strong emotion such as sadness, anxiety, or anger has appeared, she or he can ask the patient to describe the thoughts that “went through your head“ just prior to the mood shift.
    • Imagery and role play
      • Is used in generating suspected automatic thinking.
    • Checklists for automatic thought
      • checklists of thought provide an additional method to help patients identify their dysfunctional cognitions.
    • Thought recording
      • Thought recording is a standard CBT procedure for identifying automatic thoughts.
      • Although patients can log their thoughts in several ways, most begin by using the two-column technique. In this example, the patient was asked to write down automatic thoughts that occurred in situations that he associated with his depressed mood.
  • Identifying the cognitive errors
  • A. T. Beck and others described six main categories of cognitive errors:
    • Selective abstraction,
    • Arbitrary inference,
    • Absolutistic (dichotomous or all-or-nothing) thinking,
    • Magnification and minimization,
    • Personalization, and
    • Catastrophic thinking.

Existential psychotherapy

  • Components:
    • freedom
    • choice
  • existence,
  • meaning in life
  • personal responsibility
  • Precursors of existentialism: Soren Kierkegaard, Friedrich Nietzsche, Fyodor Dostoevsky.
  • Founding of ‘existentialism’ credited to Jean Paul Sartre.
  • Notable figures: Martin Heidegger, Maurice Merlau Ponty, Karl Jaspers, Martin Buber, Edmund Husserl (Phenomenology).
  • Existential Psychotherapy
    • Nature of anxiety, despair, grief, loneliness, isolation and death
    • Attempts to reconstruct the patient’s way of being himself in the world.
    • The therapeutic relationship as the psychotherapy in itself.
    • Aim is to enable the clients to reflect upon their lived experience in order to explore meaning of choices.
    • Existential approach does not have many specified techniques and must be adapted by the therapist for every new client.

Important figures:

  • Viktor Frankl (1905-1997)
    • Viktor Emil Frankl, M.D., Ph.D. (1905 –1997) was an Austrian neurologist and psychiatrist as well as a Holocaust survivor.
    • Frankl was the founder of logo therapy, which is a form of existential analysis, the “Third Viennese School of Psychotherapy”.
    • His best-selling book Man’s Search for Meaning (published under a different title in 1959: From Death-Camp to Existentialism, and originally published in 1946) chronicles his experiences as a concentration camp inmate, which led him to discover the importance of finding meaning in all forms of existence.
  • Logotherapy
    • Logotherapy is founded upon the belief that it is the striving to find a meaning in one’s life that is the primary, most powerful motivating and driving force in humans.
    • The aim of Existential Analysis is to help each person find a way of living to which s/he can give his/her inner consent to his/her own actions (“affirmation of life”). In short, to find and live out an inner ‘yes’ to one’s life.
    • Existential Analysis can be defined as a phenomenological and person-oriented psychotherapy, with the aim of leading the person to (mentally and emotionally) free experiences, to facilitate authentic decisions and to bring about a truly responsible way of dealing with life and the world.
    • Biographical work and empathic listening by the therapist contribute to an improvement in emotional understanding and accessibility.
  • Four Fundamental Motivations (FM).
    • Need to be able to accept the basic conditions of life.
    • Need to feel values and to have relationships.
    • Quest to becoming one’s own person.
    • Need to achieve something meaningful in the world.
  • Rollo May
    • Goals of Therapy
  • Understand the client and their situation, their values and beliefs;
  • Negotiate coming to terms with past, present and future crises
  • Develop truthfulness with themselves
  • Widen their perspective on themselves and the world around them;
  • Clarity on their purpose of life and learn from the past
  • Find ways of effectively communicating and being with others;
  • Make sense of the paradoxes conflicts and dilemmas of their, existence.
  • Therapeutic Techniques
    • Anti-technique orientation
      • Description, understanding and exploration of reality compared to diagnosis, treatment and prognosis.
  • Themes- The client’s attention is drawn to personal myths and stories that they have created
  • Assumptions- Clarifying implicit assumptions about people and world can be very revealing and may throw new light on a dilemma.
  • Values- Getting clarity about which aspects of life are most important and deserve making sacrifices for is a key step
  • Vicious circles- Making vicious circles of self-fulfilling prophecies explicit can be a crucial step forward. 
  • Meaning- often people assume that they know what they mean but the words they use can hide underlying emotions – questioning the superficial meaning of the client’s words and asking him/her to think of what s/he wants to express.

Biomedical model

  • Involves giving medication to patients to deal with their symptoms
  • Medications are reduced in amount used
  • Psychiatrists are the people who are allowed to prescribe medication
  • Electroconvulsive therapy (ECT) is a methods where mild electric shocks are given to the patients via electrodes that are attached to their heads to induce convulsions.
    • It is used only when necessary and under supervision