Therapeutic Approaches Class 12 NCERT Solutions

Concept used. Psychotherapy is a voluntary relationship between the person seeking treatment (the client) and the trained person who treats (the therapist). Its purpose is to help the client solve the psychological problems she or he faces. The therapeutic relationship (or therapeutic alliance) is the special bond between client and therapist that carries the change forward.

Psychotherapy is a planned, scientific way of treating psychological distress through psychological means alone. It is not one single method: there are about 400 different types. Whatever the type, all of them aim to change maladaptive behaviour, reduce the sense of personal distress, and help the client adjust better to her or his environment.

Nature of psychotherapy. Every psychotherapeutic approach shares four features:

1. There is a systematic application of the principles that underlie the different theories of therapy. The therapist does not act on guesswork.
2. Only persons who have received practical training under expert supervision can practise it, not everybody. An untrained person may unintentionally cause more harm than good.
3. The therapeutic situation involves a therapist and a client who seeks and receives help for emotional problems. The client is the focus of attention throughout the process.
4. The interaction of these two persons forms the therapeutic relationship, which is confidential, interpersonal, and dynamic. This human relationship is the vehicle for change.

Scope (goals) of psychotherapy. Psychotherapies aim at a few or all of these goals:

• Reinforcing the client's resolve for betterment.
• Lessening emotional pressure and modifying habits.
• Unfolding the potential for positive growth.
• Changing thinking patterns and increasing self-awareness.
• Improving interpersonal relations and communication.
• Facilitating decision-making and helping the client become aware of her or his choices in life.
• Helping the client relate to the social environment in a more creative and self-aware manner.

Importance of the therapeutic relationship. The therapeutic alliance has two components: it is contractual (two willing people enter a partnership to help the client) and it is of limited duration (it lasts only until the client can manage her or his own life). Its healing power rests on:

• Trust and confiding: the high level of trust lets the client unburden personal and psychological problems freely.
• Unconditional positive regard: the therapist accepts the client fully and keeps the same warm, non-judging attitude even if the client is rude or confides ``wrong'' things.
• Empathy: the therapist understands the client's plight and feels with her or him, that is, puts herself or himself in the client's shoes. Empathy is different from sympathy (pity without feeling like the other) and from cold intellectual understanding.
• Confidentiality: the therapist keeps strict secrecy and never exploits the client's trust. It stays a professional relationship throughout.

Psychotherapy is a planned, voluntary, trained treatment of psychological distress through psychological means; its scope covers changing behaviour, easing distress, and aiding growth. The therapeutic relationship, built on trust, unconditional positive regard, empathy, and confidentiality, is central because it is the vehicle through which all healing happens.

Concept used. Though all psychotherapies aim at removing human distress and fostering effective behaviour, they differ greatly in concepts, methods, and techniques. They are grouped into three broad systems: psychodynamic, behaviour, and existential (humanistic-existential) therapies. The classification is made by asking six basic questions about each system.

The three broad types. In chronological order, psychodynamic therapy emerged first, followed by behaviour therapy, while the existential therapies (also called the ``third force'') emerged last.

• Psychodynamic therapy: treats intrapsychic conflicts inside the psyche; uses free association and dream reporting; the therapist interprets the client's thoughts to give emotional insight.
• Behaviour therapy: treats faulty learning; identifies and corrects faulty conditioning and thought patterns; sets up new behavioural contingencies.
• Existential / humanistic therapy: treats the loss of meaning in life; provides a warm, accepting, non-judgmental environment in which the client grows and finds answers herself or himself.

Basis of classification. The three systems are distinguished by answering six questions:

1. What is the cause of the problem? Psychodynamic: intrapsychic conflicts. Behaviour: faulty learning of behaviours and cognitions. Existential: questions about the meaning of one's existence.
2. How did the cause come into existence? Psychodynamic: unfulfilled childhood desires and unresolved childhood fears. Behaviour: faulty conditioning, learning, and beliefs. Existential: present feelings of loneliness, alienation, and futility.
3. What is the chief method of treatment? Psychodynamic: free association and dream reporting, then interpretation. Behaviour: finding faulty patterns and setting alternate contingencies (with cognitive methods to challenge faulty thinking). Existential: a positive, accepting environment with the therapist as facilitator.
4. What is the nature of the therapeutic relationship? Psychodynamic and behaviour: the therapist understands the client better and supplies solutions. Existential: the therapist only provides a warm, empathic, secure relationship; the client explores her or his problems alone.
5. What is the chief benefit to the client? Psychodynamic: emotional insight. Behaviour: changing faulty behaviour and thought patterns into adaptive ones. Humanistic: personal growth.
6. What is the duration of treatment? Classical psychoanalysis may run for several years; recent psychodynamic versions take 10–15 sessions. Behaviour, cognitive behaviour, and existential therapies are shorter and finish in a few months.

Psychotherapies are of three broad types: psychodynamic, behaviour, and humanistic-existential. They are classified on six bases: the cause of the problem, how the cause arose, the chief method of treatment, the nature of the therapeutic relationship, the chief benefit to the client, and the duration of treatment.

Concept used. Behaviour therapy is the clinical application of learning theory principles. It assumes that psychological distress arises from faulty behaviour or thought patterns, so it works on the client's behaviour in the present. Its techniques aim to reduce the client's arousal level, change behaviour through classical or operant conditioning, or use vicarious (observational) learning. The main techniques are described below.

1. Negative reinforcement and aversive conditioning. These are the two major techniques of behaviour modification.

• Negative reinforcement: a response is strengthened because it removes or helps the person escape a painful stimulus. For example, we learn to wear woollen clothes or use a heater to avoid unpleasant cold, because avoiding the cold negatively reinforces that behaviour.
• Aversive conditioning: an undesired response is repeatedly paired with an unpleasant (aversive) consequence. For example, an alcoholic is given a mild electric shock while smelling alcohol. After repeated pairings the smell of alcohol becomes aversive, and the person gives up alcohol.

2. Positive reinforcement and token economy. If an adaptive behaviour occurs rarely, positive reinforcement is given to increase it. For example, a mother prepares the child's favourite dish whenever the child does homework on time, so the homework behaviour increases. In token economy, a person with behavioural problems is given a token every time a wanted behaviour occurs. The tokens are collected and later exchanged for a reward, such as an outing or a treat.

3. Differential reinforcement. Here unwanted behaviour is reduced and wanted behaviour is increased at the same time. One method gives positive reinforcement for the wanted behaviour and negative reinforcement for the unwanted one. A gentler, equally effective method is to positively reinforce the wanted behaviour and simply ignore the unwanted behaviour. For example, a girl who cries and sulks when she is not taken to the cinema is taken only when she asks politely, and is ignored when she cries; the polite asking increases and the crying decreases.

4. Systematic desensitisation. Introduced by Wolpe for treating phobias or irrational fears, it works on the principle of reciprocal inhibition: when two opposing forces are present at the same time, the weaker one is inhibited.

1. The therapist interviews the client to list fear-provoking situations and, with the client, prepares a hierarchy of anxiety-provoking stimuli, weakest at the bottom.
2. The therapist relaxes the client and asks her or him to imagine the least anxiety-provoking situation. The relaxation (strong) overcomes the mild anxiety (weak).
3. Over sessions the client imagines progressively stronger fearful situations while staying relaxed, until the fear is gone. The client gets systematically desensitised to the fear.

5. Modelling. Here the client learns to behave in a certain way by observing the behaviour of a role model or the therapist, who first acts as the model. This is vicarious learning (learning by observing others). By rewarding small changes, the client gradually acquires the model's behaviour.

The main techniques of behaviour therapy are negative reinforcement, aversive conditioning, positive reinforcement, token economy, differential reinforcement, systematic desensitisation (Wolpe, via reciprocal inhibition), and modelling (vicarious learning), supported by relaxation procedures.

Concept used. Cognitive distortions are ways of thinking that are general in nature but distort reality in a negative manner. They lead to errors of thinking about social reality. The explanation comes from Aaron Beck's cognitive therapy, which says that childhood experiences build core schemas (deep beliefs and action patterns), and that a later critical incident triggers these schemas to produce negative automatic thoughts and then distortions.

How a cognitive distortion forms. Beck explains it as a chain:

1. Core schema in childhood. Experiences given by the family and society build deep core schemas. For example, a child who is neglected by the parents develops the core schema ``I am not wanted''.
2. A critical incident. Later in life a critical incident occurs. For example, the same person is publicly ridiculed by a teacher in school.
3. The schema is triggered. This incident triggers the old core schema ``I am not wanted'', which now switches on.
4. Negative automatic thoughts appear. The triggered schema produces persistent, irrational negative automatic thoughts such as ``nobody loves me'', ``I am ugly'', ``I am stupid'', ``I will not succeed''.
5. Cognitive distortions and dysfunctional structures. These negative automatic thoughts are marked by cognitive distortions: general ways of thinking that twist reality negatively. The patterns are called dysfunctional cognitive structures, and they cause errors of cognition about social reality.
6. Anxiety and depression. Repeated occurrence of these thoughts leads to feelings of anxiety and depression.

Worked example. A girl neglected by her parents carries the hidden schema ``I am not wanted''. Years later, a teacher scolds her in front of the whole class. This critical incident triggers the schema. She begins to think, automatically and repeatedly, ``nobody loves me'' and ``I will never succeed''. These distorted thoughts no longer match reality (one scolding does not mean nobody loves her), but they feel true to her, and over time they produce anxiety and depression.

A cognitive distortion forms when a childhood experience builds a core schema (such as ``I am not wanted''), a later critical incident (being publicly ridiculed) triggers that schema, and the schema produces persistent negative automatic thoughts (``nobody loves me'') that twist reality negatively. Repeated, these distortions lead to anxiety and depression.

Concept used. The therapy that encourages personal growth and the actualisation of one's potential is humanistic-existential therapy. Self-actualisation is an innate or inborn force that moves a person to become more complex, balanced, and integrated. These therapies hold that psychological distress arises from loneliness, alienation, and an inability to find meaning and genuine fulfilment in life, and that healing comes when the client removes the obstacles to self-actualisation.

The core principle. Human beings are motivated by a desire for personal growth and self-actualisation and an innate need to grow emotionally. When family and society curb these needs (for example, by curbing free emotional expression), the person experiences distress. Therefore the therapy creates a permissive, non-judgmental, accepting atmosphere in which emotions can be freely expressed and the client can grow. The client, not the therapist, is responsible for the success of therapy; the therapist is only a facilitator and guide. The therapies built on this principle are described below.

1. Client-centred therapy (Carl Rogers). Rogers combined scientific rigour with individualised practice and brought the concept of the self, with freedom and choice at the core of one's being, into psychotherapy. The therapy provides a warm relationship in which the client reconnects with disintegrated feelings. The therapist offers three things in turn:

1. Empathy: understanding the client's experience as if it were the therapist's own, setting up an emotional resonance between the two.
2. Unconditional positive regard: total acceptance of the client as she or he is, not dependent on what the client reveals or does, so the client feels secure enough to explore her or his feelings.
3. Reflection: the therapist rephrases the client's statements and seeks simple clarifications, which helps the client become integrated and improves personal relationships and adjustment.

2. Gestalt therapy (Friederick ``Fritz'' Perls and Laura Perls). The German word gestalt means ``whole''. The goal is to increase the individual's self-awareness and self-acceptance. The client is taught to recognise the bodily processes and emotions that are being blocked out of 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.

3. Existential therapy and Logotherapy (Victor Frankl). Frankl, a psychiatrist and neurologist, propounded Logotherapy (logos is Greek for soul, so logotherapy means ``treatment for the soul''). It says that besides the unconscious there is a spiritual unconscious, the storehouse of love, aesthetic awareness, and values of life. Neurotic (existential) anxiety of spiritual origin arises when life's problems attach to one's existence and create meaninglessness. The goal is to help patients find meaning and responsibility in life, whatever their circumstances. The therapist shares her or his own feelings and values, keeps the emphasis on the here and now, actively discourages transference, and helps the client find the meaning of her or his being.

Humanistic-existential therapy encourages personal growth and self-actualisation. The therapies based on this principle are Carl Rogers' client-centred therapy (empathy, unconditional positive regard, reflection), Perls' Gestalt therapy (self-awareness and self-acceptance), and Frankl's existential Logotherapy (finding meaning, treatment for the soul).

Concept used. Healing factors are the elements of psychotherapy that actually bring relief to the client. They include the specific techniques used and several non-specific factors shared across all therapies. Alternative therapies are treatment options other than conventional drug treatment or psychotherapy, such as yoga and meditation.

Factors that contribute to healing. There are four main factors:

1. Techniques adopted by the therapist. The specific methods and their correct implementation heal the client. For example, in the behavioural and CBT schools, relaxation procedures and cognitive restructuring largely contribute to the healing of an anxious client.
2. The therapeutic alliance. The bond formed between therapist and client has healing properties because of the regular availability of the therapist and the warmth and empathy the therapist provides.
3. Catharsis. In the early sessions, while the client is interviewed to understand the problem, she or he unburdens emotional problems. This emotional unburdening is called catharsis, and it has healing properties.
4. Non-specific factors. These occur across different systems, clients, and therapists. They are of two kinds:

• Patient variables: factors in the client, such as motivation for change and the expectation of improvement due to the treatment.
• Therapist variables: factors in the therapist, such as a positive nature, the absence of unresolved emotional conflicts, and the presence of good mental health.

Some alternative therapies. Alternative therapies are so called because they are alternatives to conventional drug treatment or psychotherapy:

• Yoga: an ancient Indian technique from the Ashtanga Yoga of Patanjali's Yoga Sutras; refers to asanas (body postures), pranayama (breathing practices), or a combination.
• Meditation: the practice of focusing attention on the breath, an object, a thought, or a mantra. In Vipasana (mindfulness-based meditation) there is no fixed object; the person passively observes bodily sensations and thoughts.
• Acupuncture, herbal remedies, and similar practices.

In the past 25 years yoga and meditation have become popular treatment programmes for psychological distress. For example, Sudarshana Kriya Yoga (SKY) helps with stress, anxiety, PTSD, and depression, and research at NIMHANS, India, has shown that SKY reduces depression.

Healing in psychotherapy comes from four factors: the techniques used, the therapeutic alliance, catharsis (emotional unburdening), and non-specific factors (patient variables like motivation and expectation, and therapist variables like a positive nature and good mental health). Common alternative therapies are yoga, meditation (including Vipasana), acupuncture, and herbal remedies.

Concept used. Rehabilitation is the process of helping patients with severe mental disorders become self-sufficient and productive members of society after their active symptoms have reduced. The treatment of psychological disorders has two parts: reducing symptoms and improving the level of functioning or quality of life. In severe disorders such as schizophrenia, reducing symptoms is not enough, because patients may still have negative symptoms such as disinterest and lack of motivation. So rehabilitation is needed, using the techniques below.

Techniques of rehabilitation.

1. Occupational therapy. The patients are taught skills such as candle making, paper bag making, and weaving, to help them form a work discipline.
2. Social skills training. The patients are helped to develop interpersonal skills through role play, imitation, and instruction. The objective is to teach the patient to function in a social group.
3. Cognitive retraining. This is given to improve the basic cognitive functions of attention, memory, and executive functions.
4. Vocational training. After the patient improves sufficiently, vocational training helps the patient gain the skills needed to undertake productive employment.

The overall aim of rehabilitation is to empower the patient to become a productive member of society to the extent possible, and so improve her or his quality of life.

The techniques used in the rehabilitation of the mentally ill are occupational therapy (work-discipline skills like candle and paper-bag making), social skills training (interpersonal skills through role play and instruction), cognitive retraining (attention, memory, executive functions), and vocational training (skills for productive employment).

Concept used. This question contrasts two systems. A social learning (behaviour) theorist explains a phobia as faulty learning: a fear acquired and maintained through conditioning and observation. A psychoanalyst explains the same phobia as the surface sign of a hidden intrapsychic conflict, an unresolved childhood fear or unfulfilled desire pushed into the unconscious.

The social learning theorist's account. For behaviour therapies, psychological problems arise from faulty learning of behaviours and cognitions. So a fear of lizards or cockroaches is a learned response built up in three ways:

1. Classical conditioning: the lizard or cockroach (a neutral stimulus) once appeared together with a frightening event, so it became associated with fear and now triggers fear on its own.
2. Operant maintenance: every time the person avoids or escapes the lizard, the relief from fear acts as negative reinforcement. This avoidance keeps the phobia alive, because the person never stays long enough to learn that the lizard is harmless.
3. Observational (vicarious) learning: the person may have learned the fear by watching a parent or sibling react with panic to lizards or cockroaches, copying that fearful behaviour.

The treatment that follows is behavioural: systematic desensitisation (pairing relaxation with a graded hierarchy of the feared object) or modelling (watching a calm model handle the object).

The psychoanalyst's account. For psychodynamic therapy, the source of problems is intrapsychic conflict, and unfulfilled childhood desires or unresolved childhood fears lead to such conflicts. So the phobia is not really about lizards or cockroaches at all:

• The fear is a symbol. The lizard or cockroach stands for some anxiety-provoking unconscious wish, impulse, or unresolved childhood fear that the person cannot face directly.
• The anxiety attached to that hidden conflict is displaced onto a harmless external object, so the person feels the fear as a phobia of the creature rather than as the buried conflict.
• Treatment uses free association and dream reporting; the therapist interprets this material to bring the hidden conflict into awareness, giving the client emotional insight that dissolves the symptom.

A social learning theorist sees the phobia as a learned response: acquired by classical conditioning or observation and maintained by the negative reinforcement of avoidance, treatable by systematic desensitisation or modelling. A psychoanalyst sees the same phobia as a symbol: the displaced sign of a repressed intrapsychic conflict or childhood fear, treatable by free association, dream analysis, and interpretation that yields insight.

Concept used. Cognitive Behaviour Therapy (CBT) is the most popular therapy today. It combines cognitive therapy with behavioural techniques and adopts a bio-psychosocial approach: it addresses the client's distress at the biological, psychological, and social levels at once. Research has conclusively established CBT as a short and efficacious treatment for a wide range of disorders.

Problems CBT is best suited for. Because CBT is comprehensive, easy to use, applicable to many disorders, and has proven efficacy, it works well for:

• Anxiety
• Depression
• Panic attacks
• Borderline personality (and other similar disorders)

Why CBT suits these problems. The reason lies in its bio-psychosocial method. The client's distress has roots in the biological, psychological, and social realms, and CBT tackles all three:

1. The biological aspect is handled through relaxation procedures, which lower the arousal that fuels anxiety.
2. The psychological aspect is handled through behaviour therapy and cognitive therapy techniques, which correct faulty behaviour and faulty thinking.
3. The social aspect is handled through environmental manipulations.

This three-way coverage makes CBT a comprehensive, flexible, and effective treatment, which is why it is the most popular therapy in use today.

Cognitive Behaviour Therapy is best suited for a wide range of disorders, including anxiety, depression, panic attacks, and borderline personality. It works so well because its bio-psychosocial approach addresses the biological (relaxation), psychological (behavioural and cognitive techniques), and social (environmental) roots of distress together, making it short, comprehensive, and effective.