Therapies in Psychology

A therapy is a deliberate intervention which aims to trat mental disorder and make it more manageable. A therapy may be an attempt to 'cure' or it may be attempt to teach the individual how to cope up with the problem.

Therapies can be broadly classified into Somatic therapies (based on medical model) and Psychotherapies (based on mental condition of patient).

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. 

There are two major components of a therapeutic alliance. 

a) The first component is the contractual nature of the relationship in which two willing individuals, the client and the therapist, enter into a partnership which aims at helping the client overcome her/his problems. 

b) The second component of therapeutic alliance is the limited duration of the therapy. This alliance lasts until the client becomes able to deal with her/his problems and take control of her/ his life. 

1) Behavioral therapy

2) Relaxation therapy

3) Autogenic training

4) Guided Imagery

5) Systematic Desensitization

6) Exposure therapy

7) Response prevention

8) Modelling

9) Thought Stopping

10) Biofeedback

11) Aversion therapy

12) Mass Practice

13) Habit Reversal

14) Response Cost

15) Social Skills Training

16) Shaping

17) Token Economy

18) Psychotherapy

19) Cognitive therapy

1) Behavioural therapy has beneficial change in behaviour as the goal. The methods used may be based on Pavlovian classical conditioning (1927), Skinnerian operant conditioning (1938), learning

principles, experimental psychology, or behavioural sciences in general. Whereas

psychoanalysis is concerned with understanding how the individual's past

experiences (e.g. childhood trauma or conflicts) influence behaviour, The

behaviour therapy focuses on the behaviour of the here-and-now.

Criteria for behavioural treatment:

1. The problem can be defined in terms of observable and measurable

behaviour.

2. The problem is current and generally predictable.

3. Therapist and patient can agree on already defined behavioural goals.

4. Patient understands the treatment offered and accepts it.

Conditions suitable for Behavioral therapy:

a) Phobic disorders

b) Obsessive compulsive disorders

c) Generalized anxiety disorder

d) Panic disorders

e) Habit disorders

f) Sexual deviations/dysfunctions

g) Social skills deficits

h) Enuresis

Conditions where behavioral therapy may be useful:

a) Eating disorders

b) Alcohol dependence

c) Post-traumatic stress disorder

d) Marital disharmony

e) Rehabilitation of chronic psychiatric patients

f) Behaviour modification in the mentally retarded

Behavioural approaches may be categorized into:

A) Anxiety reduction techniques

a) relaxation therapy

b) autogenic training

c) guided imagery

d) systematic desensitization

e) exposure therapy

f) response prevention

g) modelling

h) thought stopping

i) biofeedback

B)  "Appetite" reduction techniques

a) aversion therapy

b) habit reversal

c) mass practice

d) response cost

C) Addition (development) of new behaviour

a) social skills training

b) modelling

c) shaping

d) token economy

2) Relaxation Therapy

The simplest form of relaxation therapy involves regular deep breathing exercises. The patient chooses a quiet spot e.g. a dimly lit room, rests on a comfortable armchair, and closes his/her eyes. He/ She thinks about nothing, and just focuses on his/her breathing. As he/she does that, he/she takes in a slow and deep breath, holds it for a few seconds, then gradually breaths out. By breathing slowly and regularly at a respiratory rate of 10 to 12 breaths per minute, he/she will begin to feel the relaxation coming upon his/her body.

Another form of relaxation exercise is muscle relaxation. First described by Jacobson (1938), it was an elaborate procedure intended to bring about reduction of individual groups of skeletal muscle tone. It involves alternate contraction followed by relaxation of different muscle groups e.g. the arms, shoulders, neck, jaw, face, etc. This can be taught individually or in groups using a video or an audiotape with recorded instructions and demonstration. It should be practiced regularly, especially in anticipation of any imminent stressor. Relaxation therapy is effective for the management of generalized anxiety disorder, mild hypertension and migraine. It can also aid in the dose reduction of benzodiazepines for the treatment of anxiety and sleep disorders.

3) Autogenic Training

Developed by Schultz (1905) from the work of Oskar Vogt, this involves a series of standard relaxation exercises followed by meditative ones to induce feelings of heaviness, warmth or cooling in parts of the body and to slow respiration. Autogenic training can be used to treat generalized anxiety disorders and stress related disorders.

4) Guided Imagery

Here the patient is presented with a series of mental images depicting peace and rest. Sceneries such as the tranquility of a clear blue lake, the morning break by the golden beach, or the cool and refreshing dew in the woods, are used to induce relaxation. Often soothing music or sounds of chirping birds or waves in the background help enhance the relaxed state further. The purpose is to involve as many sensory modalities as possible in the imagery in order to achieve optimal relaxation. The indications are similar to those prescribed with relaxation therapy.

5) Systematic Desensitization

Developed by Wolpe (1958), it begins with the construction of a list of anxiety-evoking situations in an ascending order (hierarchy). Relaxation is taught, and the patient is presented with the hierarchy of feared situations (either live or by imagination), beginning with the least feared one. Mild anxiety is experienced initially, and this is paired with relaxation exercise. Once the anxiety diminishes, the next level of feared stimulus is presented. In this way, while never experiencing intolerable anxiety, the patient proceeds from mildly anxious situations to progressively more terrifying ones. Gradually he will be able to cope with the most anxiety evoking situations. Systematic desensitization is commonly used for the treatment of phobic disorders.

6) Exposure Therapy

This is similar to systematic desensitization except that no attempt is made to relieve the anxiety during the period of exposure. Instead, with time, the anxiety will subside or disappear through a psychological process of habituation. This deliberate exposure aims at confronting the fear instead of avoiding, and can be graduated (graded-exposure) or else "flooding" the patient with the most feared situations all at once. Exposure therapy is now the mainstay of behavioural treatment for obsessive-compulsive disorder and phobias.

7) Response Prevention

Often used in combination with exposure therapy, response prevention aims at prolonging exposure to ritual-evoking cues by refraining from carrying out the rituals that would normally follow e.g. hand washing. With time, the urge to perform the rituals will subside. Response prevention can be used for obsessive compulsive disorder and eating disorders.

8) Modelling

Modelling refers to the acquisition of new behaviours by the process of imitation. The patient observes someone else carry out an action, which he has problem with. It is often used in conjunction with other techniques like exposure therapy and role-playing for the treatment of obsessive-compulsive disorder and phobias, as well as in social skills training. In the phobic child, modelling is especially useful e.g. the phobic child watches other children play with dogs and is then encouraged to join in subsequently.

9) Thought Stopping

Here chains of repetitive thoughts or obsessional ruminations are suddenly interrupted overtly e.g. by a sudden loud noise or by shouting the word "STOP!" The snapping of elastic bands worn over the wrist can also act to interrupt these thoughts. Alternatively, the patient could say the word "STOP" sub vocally, which is probably socially more acceptable.

10) Biofeedback

Biofeedback involves the use of electronic instruments to monitor small and otherwise undetectable changes in the biological state of the patient. These are then fed back to him (visually e.g. colours or by auditory means e.g. low or high pitched sounds), so that he can in turn gradually learn to alter and control them.

Biofeedback has been used to train individuals to gain control over heart rate, blood pressure, skin temperature, EEG activity and muscle tension. It has been used in the treatment of cardiac arrhythmias, hypertension, tension headache, migraine, tics, generalized anxiety and stress related disorders.

11) Aversion Therapy

In aversion therapy, the undesirable behaviour is paired with an unpleasant consequence. It may take the form of imaginable aversion (also called covert sensitization) or physical aversion e.g. electric shock. A pedophile when imagining touching a naked child shocks himself or imagines himself being arrested and publicly humiliated. Besides deviant sexual behaviour, aversion therapy has also been used in the treatment of alcohol dependence and pathological gambling. The ethanol-alcohol reaction following alcohol ingestion with disulfiram is an example of chemical aversion.

12) Mass Practice

In mass practice, the patient is asked to deliberately practice the undesirable behaviour e.g. motor tics. This will lead to boredom and eventually extinction of the behaviour.

13) Habit Reversal

As its name suggests, habit reversal attempts to extinguish undesirable habits like tics, trichotillomania, stammering and stuttering. Described by Azrin and Nunn (1977), it involves the use of a competing action, which is incompatible with the habit. A nail biter can grasp an object while a person with motor tics may be taught to contract the muscle of his upper limb isometrically.

14) Response Cost

This is a form of aversion in which the patient agrees to pay a forfeit, not necessarily monetary, for every exhibition of an undesirable behaviour. Widely practiced as the form of fines for offending the law for instance, the person could prearrange to make a donation to his least liked charitable organization for every stick of cigarette he smokes.

15) Social Skills Training

Social skills consist of verbal and non-verbal behaviours, which a person needs in order to form and/or maintain social relationships with other people. It can be taught to those who are deficient in such skills. The training involves a step-by-step Programme including the breaking down of a social interaction into different stages like initiating, maintaining and terminating social contact, personal grooming, modelling, rehearsal and role-plays, and finally video feedback.

Attention is drawn to details like eye contact, voice volume, body language, posture and social distance. It has been employed successfully to institutionalized chronic schizophrenics, depressives, psychopaths and the mentally retarded.

Although it may not play a direct therapeutic role like drugs in terms of cure for the illness, it has an important role in the overall management of the patient in enhancing a better quality of life during rehabilitation.

16) Shaping

It is a form of operant conditioning in which rewards are given for successive approximations towards the desired new behaviour e.g. a mentally retarded child dressing himself. The desired behaviour is broken into many steps, and often the therapist also acts as a model for the child to follow. It is a laborious process, and used only if a new behaviour is totally absent from the patient's repertoire.

17) Token Economy

Also based on operant conditioning as in shaping, desired behaviours necessary for day-to-day functioning are specified. A unit of exchange (the token) is presented to the patient contingent upon the occurrence of the desired behaviours. The tokens accumulated can then be exchanged for other objects or privileges. Token economy is often used to avoid institutionalization of long stay psychotic patients and the mentally retarded.

18) Psychotherapy

Psychotherapy is a form of treatment based on the systematic use of a relationship between therapist and patient (as distinct from pharmacological or social methods) to produce change in feelings, thinking and behaviour. The advantage of this definition is that it highlights how the quality of the interpersonal relationship forms the basis for therapeutic efficacy, whatever techniques are employed to this end. As with all interpersonal relationships, communication is an intrinsic aspect of psychotherapy. The predominant medium of communication involves the use of spoken language. However, non-verbal means (e.g. body sculpting, drama, music, art and play) have been employed for psychotherapeutic purposes as well.

The Goals of Psychotherapy

In general, the goals of psychotherapy are as follows:

(1) removal of distressing symptoms;

(2) altering disturbed patterns of behaviour;

(3) improved interpersonal relationships;

(4) better coping with stresses of life;

(5) personal growth and maturation.

Types of Psychotherapy

Broadly, there are 4 different theoretical approaches adopted in psychotherapy. They have their basis in:

(1) psychoanalytic tradition;

(2) cognitive-behavioural theory;

(3) interpersonal or systemic theory;

(4) existential or gestalt philosophy.

Psychotherapy can be carried out in 4 modes, namely with:

(1) individuals

(2) couples

(3) families

(4) groups

By convention and for historical reasons, individual psychotherapy is often identified by its theoretical orientation. Thus, we have 4 main types of individual psychotherapy, namely psychodynamic psychotherapy, cognitive-behavioural psychotherapy, interpersonal psychotherapy and existential/experiential psychotherapy for individuals. When the mode of delivery involves more than one person, the theoretical orientation is often left out in the reference (i.e. couple or marital therapy, family therapy and group therapy).

Despite the diversity of techniques employed in psychotherapy, the following are beneficial functions that most, if not all effective psychotherapies have in common:

(1) Developing a therapeutic relationship

(2) Generating positive expectations

(3) Facilitating cognitive and experiential learning

(4) Facilitating emotional arousal and catharsis

(5) Engendering a sense of mastery

(6) Application of new skills developed

19) Cognitive therapy (CT)

Cognitive therapy (CT) is a brief structured form of psychotherapy, which deals with the identification of maladaptive cognitions (thoughts, attitudes, images and dreams) and its substitution with more adaptive ones. Cognitions, emotions, behaviours, bodily symptoms and environmental factors are intricately linked.

Change in any one of these may lead to changes in the other four. As emotions are less directly amenable to change, changes of cognitions, behaviour and the environment are more practical means of effecting emotional changes. CT is concerned primarily with current problems the sufferer is faced with and possible solutions. The therapist is active and interactive, seeking to secure a collaborative relationship with the client. The therapy is based on empirical data and is education and skills oriented with the aim of guiding the client to “discover“ solutions. There is a myth that CT is not interested in emotions or the client’s past. Contrary to these beliefs, in CT, emotions and shifts of emotions are important to the therapy. Strong emotions are often the best time to explore cognitions (“hot cognitions”).

Although CT is primarily focused on current problems the client faces, the past is extremely important in helping both client and therapist understand and conceptualize the current problem(s).

Cognitive therapy has its roots in the empirical method much espoused by the early Greek philosophers. Indeed, “Socratic” questioning (inductive questioning which seeks to lead the client to answers based on knowledge already available to the patient) is held to be a key therapeutic tool in CT. Until the end of the Second World War, analytical psychotherapy was the primary form of psychotherapy practiced in much of the Western world. In the fifties, behaviour therapy became popular. In the sixties, both Aaron Beck and Albert Ellis independently introduced cognitive models mental distress and its accompanying therapy - cognitive therapy. They hypothesized that thinking mistakes were behind much of the emotional distress in people and that people would be able to change the way they feel if they first changed the way they think. 

Today, cognitive behaviour therapy stands alongside analytical psychotherapy as the most commonly prescribed form of psychotherapy in the Western world. Efforts by

Anthony Ryle and his team have focused on merging psychoanalytical and cognitive-behavioural principles (cognitive-analytical therapy).

CT is an empirical method, driven by cognitive models derived from social psychology, cognitive psychology, psychiatry, behaviour therapy and dynamic psychotherapy. Its efficacy is supported by empirical scientific studies. The nature of CT has lent itself well to the manualisation of therapy, aiding standardization of research and its availability to the lay-person in the form of “self-help manuals”.

CT is indicated for the following conditions: Anxiety disorders, Depressive disorders; Marital Problems; Personality disorders; Eating disorders; Additive disorders and Somatoform disorders. It is a useful adjunct in bipolar and psychotic conditions, where it can be used to improve the detection of early signs of relapse and improve medication compliance. Modifications may have to be made when CT is used in children, those with psychotic conditions and those with personality disorders.