Chapter 5 — Therapeutic Approaches

Psychotherapy is a voluntary relationship between the client (one seeking treatment) and the therapist (one who treats), aimed at solving the psychological problems faced by the client. Its goals include reinforcing the client's resolve for betterment, lessening emotional pressure, unfolding potential for positive growth, modifying habits, changing thinking patterns, increasing self-awareness, improving interpersonal relations, facilitating decision-making, and relating to one's social environment in a more self-aware manner.

Psychotherapies are classified into three broad groups: psychodynamic, behaviour, and existential psychotherapies. In chronological order, psychodynamic therapy emerged first, followed by behaviour therapy, while existential therapies (also called the third force) emerged last.

The two major components of a therapeutic alliance are: (1) the contractual nature of the relationship, where two willing individuals — the client and the therapist — enter a partnership aimed at helping the client overcome problems; and (2) the limited duration of the therapy, which lasts only until the client is able to deal with problems and take control of life.

In sympathy, one has compassion and pity towards another's suffering but cannot feel like that person. Intellectual understanding is cold — the person understands the situation but neither feels like the other nor shows sympathy. Empathy means understanding the plight of another person and feeling like that person — putting oneself in the other person's shoes. Empathy enriches the therapeutic relationship and transforms it into a healing relationship.

Systematic desensitisation was introduced by Wolpe for treating phobias or irrational fears. The client and therapist together prepare a hierarchy of anxiety-provoking stimuli, with the least anxiety-provoking at the bottom. The therapist relaxes the client and asks them to think about the least anxiety-provoking situation first. The principle of reciprocal inhibition operates here: relaxation (the stronger force) inhibits anxiety (the weaker force). Over sessions, the client tolerates progressively more severe fear-provoking situations while remaining relaxed, becoming systematically desensitised.

Rational Emotive Therapy (RET) was formulated by Albert Ellis. Its central thesis is that irrational beliefs mediate between antecedent events and their consequences. The first step in RET is the antecedent-belief-consequence (ABC) analysis: antecedent events causing distress are noted, then the client's irrational beliefs — characterised by thoughts with 'musts' and 'shoulds' — are identified through questionnaires and interviews and refuted by the therapist through gentle, non-directive questioning.

According to Aaron Beck, childhood experiences provided by family and society develop core schemas — systems of beliefs and action patterns. A critical incident later in life can trigger these schemas, leading to negative automatic thoughts such as 'nobody loves me' or 'I will not succeed'. These thoughts are characterised by cognitive distortions — ways of thinking that are general in nature but distort reality in a negative manner, called dysfunctional cognitive structures. Therapy aims at cognitive restructuring to reduce anxiety and depression.

CBT is described as the most popular therapy presently. It adopts a bio-psychosocial approach, combining cognitive therapy with behavioural techniques to address the biological (via relaxation procedures), psychological (via behaviour and cognitive therapy), and social (via environmental manipulations) aspects of distress. Research has conclusively established CBT to be a short and efficacious treatment for a wide range of psychological disorders such as anxiety, depression, panic attacks, and borderline personality.

Logotherapy was propounded by Victor Frankl, a psychiatrist and neurologist. Logos is the Greek word for soul, so Logotherapy means treatment for the soul. Frankl called the process of finding meaning even in life-threatening circumstances 'meaning making'. Neurotic anxieties arise when problems of life are attached to physical, psychological, or spiritual aspects of existence. The goal of logotherapy is to help patients find meaning and responsibility in their life irrespective of their life circumstances.

Client-centred therapy was given by Carl Rogers, who brought into psychotherapy the concept of self, with freedom and choice as the core of one's being. Unconditional positive regard means the positive warmth of the therapist is not dependent on what the client reveals or does in therapy sessions — the therapist continues to show the same warmth even if the client is rude or confides undesirable thoughts. This ensures the client feels secure and can trust the therapist. The therapist acts only as a facilitator.

Gestalt therapy was given by Freiderick (Fritz) Perls together with his wife Laura Perls. The German word Gestalt means 'whole'. The goal of this therapy is to increase an individual's self-awareness and self-acceptance. The client is taught to recognise bodily processes and emotions being blocked from awareness; the therapist encourages the client to act out fantasies about feelings and conflicts. This therapy can also be used in group settings.

SKY is a rapid breathing technique that induces hyperventilation. Research at the National Institute of Mental Health and Neurosciences (NIMHANS), India, has shown that SKY reduces depression. It is found to be a beneficial, low-risk, low-cost adjunct to treatment of stress, anxiety, PTSD, depression, stress-related medical illnesses, substance abuse, and rehabilitation of criminal offenders. It has also been used as a public health intervention to alleviate PTSD in survivors of mass disasters. Yoga techniques in general enhance well-being, mood, attention, mental focus, and stress tolerance.

Token economy is a technique in which persons with behavioural problems are given a token as a reward every time a wanted behaviour occurs. The tokens are collected and later exchanged for a reward such as an outing for the patient or a treat for the child. This uses positive reinforcement to increase the frequency of wanted behaviours.

Catharsis refers to the process of emotional unburdening. At the outset of therapy, while the patient is being interviewed in 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, and it has healing properties because releasing pent-up emotional distress itself provides relief.

Rehabilitation aims to empower patients to become productive members of society to the extent possible. It involves: occupational therapy (teaching skills such as candle making, paper bag making, and weaving to form work discipline); social skills training (developing interpersonal skills through role play, imitation, and instruction so the patient can function in a social group); cognitive retraining (improving attention, memory, and executive functions); and vocational training (gaining skills for productive employment after sufficient improvement).

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