Therapeutic approach clinical Psychology


Chapter 5 –
Therapeutic
Approaches

NATURE AND PROCESS OF PSYCHOTHERAPY
Psychotherapies aim at changing the maladaptive behaviors,
decreasing the sense of personal distress, and helping the client
to adapt better to her/his environment.
All psychotherapies aim at a few or all of the following goals :
(i) Reinforcing client’s resolve for betterment.
(ii) Lessening emotional pressure.
(iii) Unfolding the potential for positive growth.
(iv) Modifying habits.
(v) Changing thinking patterns.
(vi) Increasing self-awareness.
(vii) Improving interpersonal relations and communication.viii)
Facilitating decision-making. (ix) Becoming aware of one’s
choices in life.

(x) Relating to one’s social environment in a more creative and
self-aware manner.
Therapeutic Relationship
The special relationship between the client and the therapist is
known as the therapeutic relationship or alliance.
There are two major components of a therapeutic alliance. The
first component is the contractual nature of the relationship
The second component of therapeutic alliance is the limited
duration of the therapy.
The therapist conveys by her/his words and behaviors that s/he
is not judging the client and will continue to show the same
positive feelings towards the client even if the client is rude or
confides all the ‘wrong’ things that s/he may have done or
thought about. This is the unconditional positive regard which
the therapist has for the client. The therapist has empathy for the

client. It means understanding things from the other person’s
perspective, i.e. putting oneself in the other person’s shoes.


PSYCHOTHERAPIES
PSYCHODYNAMIC
THERAPY
BEHAVIOURAL
THERAPY
EXISTENTIAL
THERAPY

Classification of psychotherapies is
based on the following parameters:
 What is the cause, which has led to the
problem?
 Psychodynamic therapy- view intrapsychic conflicts are the source
of psychological problems.

 Behavior therapies- psychological problems arise due to faulty
learning of behaviors and cognitions.
 Existential therapies- 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.
 Behavior therapy- faulty conditioning patterns, faulty learning,
and faulty thinking and beliefs lead to psychological problems.
 Existential therapy- current feelings of loneliness, alienation,
sense of futility of one’s existence, etc cause psychological problems.


3. What is the chief method of treatment?
 Psychodynamic therapy- free association and reporting of dreams
to elicit the thoughts and feelings of the client.
 Behavior therapy- cognitive methods employed in this type of
therapy challenge the faulty thinking patterns of the client to help her/him
over come psychological distress.
 Existential therapy- provides a therapeutic environment which is positive,
accepting, and non- judgmental. The client arrives at the solutions through
a process of personal growth.

4. What is the nature of the therapeutic relationship
between the client and the therapist?
 Psychodynamic therapy- therapist understands the client’s intrapsychic
conflicts better than the client and hence it is the therapist who interprets the
thoughts and feelings of the client to her/him so that s/he gains an
understanding of the same.
 The behavior therapy- therapist is able to discern the faulty behavior
and thought patterns of the client. It further assumes that the therapist
is capable of finding out the correct behavior and thought patterns,
which would be adaptive for the client.
 Both the psychodynamic and the behavior therapies assume that the
therapist is capable of arriving at solutions to the client’s problems.
 Existential therapy- therapist merely provides a warm, empathic
relationship in which the client feels secure to explore the nature and
causes of her/his problems by herself/himself.


5. What is the chief benefit to the client?
 Psychodynamic therapy- values emotional insight as the important
benefit that the client derives from the treatment. The client’s symptoms
and distresses reduce as a consequence of this emotional insight.
 The behavior therapy considers changing faulty behavior and
thought patterns to adaptive ones as the chief benefit of the treatment.
 The humanistic therapy values personal growth as the chief benefit.
Personal growth is the process of gaining increasing understanding of
oneself,and one’s aspirations, emotions and motives.


6. What is the duration of treatment?
 The duration of classical psychoanalysis may continue for several
years or 10–15 sessions.
 Behavior and cognitive behavior therapies as well as existential
therapies are shorter and are completed in a few months.


Steps in the Formulation of a Client’s Problem
The clinical formulation has the following advantages:
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,
timing of the techniques, and expectations of outcome of the therapy
depend upon the clinical formulation.

Methods of Eliciting the Nature of Intrapsychic Conflict
The first step in the treatment is to elicit this intrapsychic conflict.
Psychoanalysis has invented free association and dream
interpretation as two important methods for eliciting the
intrapsychic conflicts.
Once client is encouraged to freely associate one thought with
another, and this method is called the method of free association. 
This free uncensored verbal narrative of the client is a window into the
client’s unconscious to which the therapist gains access.
Along with this technique, the client is asked to write down her/his
dreams upon waking up.

The images of the dreams are symbols which signify intrapsychic
forces. Dreams use symbols because they are indirect expressions
and hence would not alert the ego.
Modality of Treatment
Transference and Interpretation are the means of treating the
patient.
As the unconscious forces are brought into the conscious client
starts identifying the therapist with the authority figures of the
past, usually childhood. This is the process of transference.
The therapist encourages this process because it helps
her/him in understanding the unconscious conflicts of the
client. 
The client acts out her/his frustrations, anger, fear, and
depression that s/he harbored towards that person in the past,
but could not express at that time. The therapist becomes a

substitute for that person in the present. This stage is called
transference neurosis.
There is the positive transference in which the client idolizes, or
falls in love with the therapist, and seeks the therapist’s approval.
Negative transference is present when the client has feelings of
hostility, anger, and resentment towards the therapist.
The process of transference is met with resistance . Due to
resistance, the client opposes the progress of therapy in order to
protect herself/himself from the recall of painful unconscious
memories.
Conscious resistance is present when the client deliberately
hides some information. Unconscious resistance is assumed to
be present when the client becomes silent during the therapy
session, recalls trivial details without recalling the emotional
ones, misses appointments, and comes late for therapy sessions.

Interpretationis the fundamental mechanism by which
change is effected. Confrontation and clarification are the two
analytical techniques of interpretation.
In confrontation, the therapist points out to the client an aspect
of her/his psyche that must be faced by the client. Clarification
is the process by which the therapist brings a vague or confusing
event into sharp focus. This is done by separating and
highlighting important details about the event from unimportant
ones.
The repeated process of using confrontation, clarification, and
interpretation is known as working through.
Working through helps the patient to understand herself/himself
and the source of the problem and to integrate the uncovered
material into her/his ego.
The outcome of working through is insight. As this process
continues, the client starts to understand herself/himself better at

an intellectual and emotional level, and gains insight into her/his
conflicts and problems.
Insight is the end point of therapy as the client has gained a new
understanding of herself/himself. In turn, the conflicts of the past,
defence mechanisms and physical symptoms are no longer
present and the client becomes a psychologically healthy person.
Psychoanalysis is terminated at this stage.
Duration of Treatment
Psychoanalysis lasts for several years, with one hour session
for 4-5 days per week.
There are three stages in the treatment. Stage one is the initial
phase. The client becomes familiar with the routines, and
rapport formation.

Stage two is the middle phase, which is a long process. It is

characterized by transference, resistance on the part of
the client, and confrontation and clarification on part of
therapist. All these processes finally lead to insight.
The third phase is the termination phase wherein the relationship
with the analyst is dissolved.

Behavior therapies postulate that psychological distress arises because of
faulty behavior patterns or thought patterns.
The symptoms of the client and the clinical diagnosis are the guiding factors in
the selection of the specific techniques or interventions to be applied.
Method of Treatment
Behavioral analysis is conducted to find malfunctioning behaviors, the
antecedents
of faulty learning, and the factors that maintain or continue
faulty learning.
Malfunctioning behaviors are those behaviors which cause distress to the
client.
Antecedent factors are those causes which predispose the person to indulge
in that behavior.

Maintaining factors are those factors which lead to the persistence of the
faulty behavior.


Once the faulty behaviors which cause distress, have been identified, a treatment
package is chosen.
The aim of the treatment is to extinguish or eliminate the faulty behaviors and substitute
them with adaptive behavior patterns.
The therapist does this through establishing antecedent operations and consequent
operations.
Antecedent operations control behavior by changing something that precedes such a
behavior. The change can be done by increasing or decreasing the reinforcing value of
a particular consequence.
Consequent operation is reinforcing person after the desired behavior is achieved.

Behavioural Techniques
Negative reinforcement and aversive conditioning are the two major techniques of
behavior modification.
Negative reinforcement refers to following an undesired response with an outcome
that is painful or not liked.
Aversive conditioning 
refers to repeated association of undesired response with an
aversive consequence.
If an adaptive behavior occurs rarely, positive reinforcement is given to increase the
deficit.
Persons with behavioral problems can be given a token as a reward every time a
wanted behavior occurs. The tokens are collected and exchanged for a reward such as
an outing for the patient or a treat for the child. This is known as token economy.

The other method is to positively reinforce the wanted behavior and ignore the
unwanted behavior.
Systematic desensitization 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 relaxes the client and asks the client 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.
The principle of reciprocal inhibition operates here. This principle states that
the presence of two mutually opposing forces at the same time, inhibits the
weaker force.

Modelling is the procedure wherein the client learns to behave in a certain
way by observing the behavior of a role model or the therapist who initially acts
as the role model.

Cognitive therapies locate the cause of psychological distress in irrational thoughts
and beliefs.
Rational Emotive Therapy (RET)- (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 .
Antecedent events, which caused the psychological distress, are noted. The client is
also interviewed to find the irrational beliefs, which are distorting the present reality.
These beliefs are characterised by thoughts with ‘musts’ and ‘shoulds’. This distorted
perception of the antecedent event due to the irrational belief leads to the
consequence, i.e. negative emotions and behaviours.
In the process of RET, the irrational beliefs are refuted by the therapist through a
process of non-directive questioning.

Another cognitive therapy is that of Aaron Beck.
His theory of psychological distress characterized by anxiety or depression.
Negative automatic thoughts such as “nobody loves me”, “I am ugly”, “I am
stupid”, “I will not succeed”, “I am not wanted” etc. are characterized by
cognitive distortions.
Cognitive distortions are 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.
They lead to errors of cognition about the social reality.
Similar to behavior therapy, cognitive therapy focuses on solving a specific
problem of the client. Unlike psychodynamic therapy, cognitive therapy is

open, i.e. the therapist shares her/his method with the client. It is short, lasting
between 10–20 sessions.
Cognitive Behavior Therapy
The most popular therapy presently is the Cognitive Behavior Therapy (CBT).
Research show CBT to be 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 behavioral techniques.
The rationale is that the client’s distress has its origins in the biological, psychological,
and social realms. Hence, addressing the biological aspects through relaxation
procedures, the psychological ones through behavior therapy and cognitive

therapy techniques and the social ones with environmental manipulations makes CBT
a comprehensive technique which is easy to use, applicable to a variety of disorders,
and has proven efficacy.
Humanistic-existential Therapy
The humanistic-existential therapies postulate that
psychological distress arises from feelings of loneliness,
alienation, and an inability to find meaning and genuine
fulfilment in life.
Self-actualisation is defined as an innate or inborn force that
moves the person to become more complex, balanced, and
integrated.

Therefore, 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.

The fundamental assumption is that the 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.
 Existential Therapy
 Victor Frankl, a psychiatrist and neurologist propounded the Logotherapy.
Logos is the Greek word for soul and Logotherapy means treatment for
the soul.
 Frankl calls this process of finding meaning even in life-threatening
circumstances as the process of meaning making. The basis of meaning
making is a person’s quest for finding the spiritual truth of one’s
existence.
 The goal of logotherapy is to help the patients to find meaning and
responsibility in their life irrespective of their life circumstances. The therapist

emphasises the unique nature of the patient’s life and encourages them to
find meaning in their life.
 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.


Client-centred Therapy
 Client-centred therapy was given by Carl Rogers.
 Rogers brought into psychotherapy the concept of self, with
freedom and choice as the core of one’s being.
 The therapy provides a warm relationship in which the client can
reconnect with her/his disintegrated feelings. The therapist
shows empathy, unconditional positive regard.
 Empathy sets up an emotional resonance between the therapist
and the client. This unique unconditional warmth ensures that
the client feels secure and can trust the therapist.


Gestalt Therapy
 The German word gestalt means ‘whole’.
 This therapy was given by Freiderick (Fritz) Perls
together with his wife Laura Perls.
 The goal of gestalt therapy is to increase an individual’s
self-awareness and self- acceptance.
 The client is taught to recognize 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.

Biomedical Therapy
Prescription of medicines for treatment of mental disorders is
done by qualified medical professionals known as psychiatrists.
Severe mental disorders such as schizophrenia or bipolar
disorder require anti-psychotic drugs. Common mental
disorders such as generalized anxiety or reactive depression
may also require milder drugs.
The medicines prescribed to treat mental disorders can cause
side-effects which need to be understood and monitored. Hence,
it is essential that medication is given under proper medical
supervision.
These drugs can cause addiction, and harm the brain and
the body. Therefore, it is dangerous to self- medicate with drugs
which affect the mind.


Electro-convulsive Therapy (ECT) is another form of
biomedical therapy. Mild electric shock is given via
electrodes to the brain of the patient to induce convulsions.
The shock is given by the psychiatrist only when it is necessary
for the improvement of the patient.
ECT is not a routine treatment and is given only when drugs
are not effective in controlling the symptoms of the patient.

Factors Contributing to Healing
in Psychotherapy
1. The implementation of the same with the patient/client.
If the behavioral 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. The therapeutic alliance, which is formed between the
therapist and the patient/client. 
3. In the initial sessions to understand the nature of the
problem, s/he unburdens the emotional problems being faced.
This process of emotional unburdening is known as
catharsis.
4. Non-specific factors attributable to the client/patient are
motivation for change, expectation of improvement due to the
treatment, etc. These are called patient variables. Non-specific

factors attributable to the therapist are positive nature,
absence of unresolved emotional conflicts, presence of
good mental health, etc. These are called therapist variables.


1. Informed consent needs to be taken.
2. Confidentiality of the client should be maintained.
3. Alleviating personal distress and suffering should be the goal
of all attempts of the therapist.
4. Integrity of the practitioner -client relationship is important.
5. Respect for human rights and dignity.
6. Professional competence and skills are essential.
Ethics in Psychotherapy


Yoga, meditation, acupuncture, herbal remedies etc. Yoga as it is
commonly called body posture component or to breathing
practices or pranayama. Meditation refers to the practice of
focusing attention on breath or on an object or thought or a
mantra.
Found to be a beneficial, to the treatment of stress, anxiety,
post-traumatic stress disorder (PTSD), depression, stress-
related medical illnesses, substance abuse, and rehabilitation
of criminal offenders.
Alternative Therapies

REHABILITATION OF THE MENTALLY
ILL
The treatment of psychological disorders has two components,
i.e. reduction of symptoms, and improving the level of
functioning or quality of life. Many patients suffer from
negative symptoms such as disinterest and lack of motivation to
do work or to interact with people.
Rehabilitation is required to help such patients become
selfsufficient. The aim of rehabilitation is to empower the
patient to become a productive member of society to the
extent possible.
In rehabilitation, the patients are given occupational therapy,
social skills training, and vocational therapy.
In occupational therapy, the patients are taught skills such as
candle making, paper bag making and weaving to help them to

form a work discipline. Social skill training help them improves
their social life, cognition, and vocational therapy make them
independent.
Summary
Psychotherapy is a treatment for the healing of psychological
distress.
Psychoanalysis, behavioral, cognitive and humanistic-existential
are the important systems of psychotherapy.
The important components of psychotherapy are the clinical
formulation, i.e. statement of the client’s problem and treatment
in the framework of a particular therapy. 
Therapeutic alliance is the relation between the therapist and the
client in which the client has trust in the therapist and the
therapist has empathy for the client.

Alternative therapies such as some yogic and meditative
practices have been found to be effective in treating certain
psychological disorders.
Rehabilitation of the mentally ill is necessary to improve their
quality of life once their active symptoms are reduced.

Therapeutic approach clinical Psychology

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