Complete solutions to all nine Review Questions from the NCERT textbook Psychology, Chapter 5 “Therapeutic Approaches”, in the English edition’s own wording, followed by the three in-text Activity boxes the chapter prints (Activity 5.1 to 5.3) and the chapter’s Box 5.1 on clinical formulation. Try answering each question yourself first, then check your answer here.
1 Nature, Scope and the Therapeutic Relationship
Q. Describe the nature and scope of psychotherapy. Highlight the importance of therapeutic relationship in psychotherapy.
Answer: Psychotherapy is a voluntary relationship between the person seeking treatment (the client) and the therapist, aimed at helping the client solve their psychological problems, so that problems may be freely discussed once trust is built. Its scope covers changing maladaptive behaviours, decreasing personal distress, and helping the client adapt better to their environment, including marital, occupational and social adjustment. Every psychotherapeutic approach shares four characteristics: systematic application of theory-based principles, practice only by trained persons (an untrained person can unintentionally cause more harm than good), a therapist-client interaction in which the client is the focus of attention, and a confidential, interpersonal, dynamic relationship. The therapeutic relationship (alliance) is central to this: it has two components, being contractual (two willing individuals enter a partnership) and of limited duration (lasting only until the client can handle their own life). This human relationship is the actual vehicle for change: it must be trusting and confiding, built on the therapist’s empathy, genuineness, warmth and unconditional positive regard, and it must remain strictly confidential and professional throughout.
2 Types of Psychotherapy and Their Basis
Q. What are the different types of psychotherapy? On what basis are they classified?
Answer: The chapter classifies psychotherapies into three broad groups, in the chronological order they emerged: psychodynamic therapy (first), behaviour therapy (second), and existential therapy, also called “the third force” (last). They are classified on six parameters: the cause of the problem, how the cause came into existence, the chief method of treatment, the nature of the therapeutic relationship, the chief benefit to the client, and the duration of treatment. On these parameters: (1) Cause. Psychodynamic: intrapsychic conflicts within the psyche; behaviour: faulty learning of behaviours and cognitions; existential: questions about the meaning of one’s life and existence. (2) How the cause arose. Psychodynamic: unfulfilled desires and unresolved fears of childhood; behaviour: faulty conditioning patterns, faulty learning, and faulty thinking and beliefs; existential: present feelings of loneliness, alienation and a sense of futility. (3) Chief method. Psychodynamic: free association and reporting of dreams, with the material interpreted to the client to help confront and resolve the conflicts; behaviour: identifying faulty conditioning patterns and setting up alternate behavioural contingencies, with cognitive methods challenging faulty thinking; existential: a positive, accepting, non-judgmental environment in which the client arrives at solutions through personal growth. (4) Therapeutic relationship. Psychodynamic: the therapist understands the client’s conflicts better than the client and interprets them; behaviour: the therapist discerns the faulty patterns and finds the adaptive ones; existential: the therapist merely provides a warm, empathic relationship in which the client explores the problem herself/himself. (5) Chief benefit. Psychodynamic: emotional insight (understanding the conflicts intellectually, accepting them emotionally and changing one’s emotions towards them); behaviour: changing faulty behaviour and thought patterns to adaptive ones; humanistic therapy: personal growth. (6) Duration. Classical psychoanalysis may continue for several years, though several recent psychodynamic versions take 10-15 sessions; behaviour, cognitive behaviour and existential therapies are shorter and are completed in a few months.
3 Techniques Used in Behaviour Therapy
Q. Discuss the various techniques used in behaviour therapy.
Answer: Behaviour therapy is the clinical application of learning theory, applied through behavioural analysis (interviewing the client and family to find the malfunctioning behaviour, its antecedent factors and its maintaining factors), followed by a treatment package built from antecedent operations (changing what precedes the behaviour) and consequent operations (changing what follows it). The principles of these techniques are to reduce the client’s arousal level, to alter behaviour through classical or operant conditioning with different contingencies of reinforcement, and to use vicarious learning procedures if necessary. Negative reinforcement and aversive conditioning are the two major techniques of behaviour modification. The named techniques are: negative reinforcement (escaping/avoiding a painful stimulus, e.g. wearing woollens to avoid cold); aversive conditioning (repeatedly pairing an undesired response with an aversive consequence, e.g. a mild shock paired with the smell of alcohol); positive reinforcement (rewarding a rare adaptive behaviour to increase it, e.g. a favourite dish for homework done on time); token economy (tokens given for wanted behaviour, collected and exchanged for a reward such as an outing); differential reinforcement (reducing unwanted and increasing wanted behaviour simultaneously, either by positive reinforcement of the wanted behaviour and negative reinforcement of the unwanted behaviour together, or by positively reinforcing the wanted behaviour and ignoring the unwanted one, which is less painful and equally effective, e.g. the cinema/sulking-girl example); relaxation procedures, such as progressive muscular relaxation and meditation, to reduce the anxiety that is an antecedent factor for faulty behaviour (in progressive muscular relaxation the client contracts one muscle group at a time, e.g. the forearm, then lets go of the tension, and with repeated practice learns to relax all the muscles of the body); systematic desensitisation (introduced by Wolpe, for phobias, using a hierarchy of feared situations and the principle of reciprocal inhibition); and modelling (learning a behaviour by observing a role model or the therapist, through vicarious learning, with small changes rewarded progressively).
4 How Cognitive Distortions Take Place
Q. Explain with the help of an example how cognitive distortions take place.
Answer: According to Aaron Beck’s cognitive therapy, childhood experiences provided by family and society develop core schemas: belief-and-action-pattern systems. For example, a client neglected by their parents as a child develops the core schema “I am not wanted.” During the course of life, a critical incident occurs, such as being publicly ridiculed by a teacher in school, which triggers the core schema, leading to negative automatic thoughts (“nobody loves me”, “I am ugly”, “I am stupid”, “I will not succeed”). These negative automatic thoughts are characterised by cognitive distortions: general ways of thinking that distort reality in a negative manner, called dysfunctional cognitive structures, which lead to errors of cognition about social reality. Repeated occurrence of these thoughts develops feelings of anxiety and depression. The therapist then uses gentle, non-threatening questioning to dispute the client’s beliefs and thoughts, aiming for cognitive restructuring, which in turn reduces the anxiety and depression.
5 Therapies Based on Personal Growth and Self-Actualisation
Q. Which therapy encourages the client to seek personal growth and actualise their potential? Write about the therapies which are based on this principle.
Answer: Humanistic-existential therapy is based on this principle: human beings are motivated by a need for personal growth and self-actualisation, an innate force that moves a person to become more complex, balanced and integrated. When society and family curb this need, psychological distress results; healing requires free emotional expression in a permissive, non-judgmental, accepting atmosphere, with the client having the freedom and responsibility to control their own behaviour and the therapist acting merely as facilitator. Three named therapies follow this principle: Existential Therapy, Victor Frankl’s Logotherapy (“treatment for the soul”), which helps the client find meaning through “meaning making,” addressing existential anxiety of spiritual origin, discouraging transference and emphasising the “here and now”; Client-centred Therapy, Carl Rogers’s therapy, which uses empathy, unconditional positive regard and reflection to help the client reconnect with disintegrated feelings and become their real self; and Gestalt Therapy, given by Fritz and Laura Perls, which increases the client’s self-awareness and self-acceptance by encouraging them to act out fantasies about feelings and conflicts, and can also be used in group settings.
6 Factors Contributing to Healing and Alternative Therapies
Q. What are the factors that contribute to healing in psychotherapy? Enumerate some of the alternative therapies.
Answer: Four factors contribute to healing in psychotherapy: the techniques adopted by the therapist and their implementation (e.g. relaxation and cognitive restructuring in CBT); the therapeutic alliance itself, which has healing properties from the therapist’s regular availability, warmth and empathy; catharsis, the emotional unburdening that occurs while the client’s problem is understood in the initial sessions; and non-specific factors that occur across all systems, clients and therapists, split into patient variables (motivation for change, expectation of improvement) and therapist variables (positive nature, absence of unresolved emotional conflicts, good mental health). Alternative therapies, offered as alternatives to conventional drug treatment or psychotherapy, include yoga, meditation, acupuncture and herbal remedies. Yoga (detailed in Patanjali’s Yoga Sutras, Ashtanga Yoga) today commonly means asanas and/or pranayama; meditation focuses attention on breath, an object, thought or mantra, and Vipasana (mindfulness-based) meditation uses no fixed object at all. Sudarshana Kriya Yoga (SKY), a rapid-breathing technique, is a beneficial, low-risk, low-cost adjunct to the treatment of stress, anxiety, PTSD, depression, stress-related medical illnesses and substance abuse, with NIMHANS, India research showing it reduces depression; Kundalini Yoga, combining pranayama with mantra chanting, was found effective for obsessive-compulsive disorder by the Institute for Non-linear Science, University of California, San Diego, USA.
7 Techniques Used in Rehabilitation of the Mentally Ill
Q. What are the techniques used in the rehabilitation of the mentally ill?
Answer: Rehabilitation aims to empower the patient to become a productive member of society to the extent possible, especially where symptom reduction alone (as in severe disorders like schizophrenia) may not improve quality of life because negative symptoms such as disinterest and lack of motivation persist. Its techniques are: occupational therapy, teaching skills such as candle making, paper bag making and weaving, to help the patient form a work discipline; social skills training, using role play, imitation and instruction to develop interpersonal skills so the patient can function in a social group; cognitive retraining, to improve basic cognitive functions of attention, memory and executive functions; and, once the patient has improved sufficiently, vocational training, which helps them gain the skills necessary to undertake productive employment.
8 A Phobic Fear of Lizards/Cockroaches: Social-Learning and Psychoanalytic Accounts
Q. How would a social learning theorist account for a phobic fear of lizards/cockroaches? How would a psychoanalyst account for the same phobia?
Answer: A social learning theorist, working within the behaviour-therapy framework this chapter teaches, would explain the phobia as a case of faulty learning rather than an inborn fear. The chapter’s own behavioural-analysis method identifies three things: the malfunctioning behaviour (the fear response itself, so intense that it disrupts the person’s normal activities), the antecedent factor (an event that predisposed the person toward this fear: for instance, having witnessed someone else react with strong fear or disgust to a lizard/cockroach, since fear can be acquired through vicarious/observational learning, or having had a genuinely frightening encounter with one), and the maintaining factor (the relief the person feels every time they avoid or escape the feared object, which is a form of negative reinforcement that keeps the avoidance behaviour going). Treated this way, the phobia is unlearned using the chapter’s own named technique for exactly this purpose: systematic desensitisation, in which a hierarchy of lizard/cockroach-related situations is built from least to most frightening, and the person is progressively desensitised while relaxed, through the principle of reciprocal inhibition.
The psychoanalyst’s account: A psychoanalyst would explain the same phobia through the psychodynamic view, which the chapter sets out when it compares the three families of psychotherapy. Psychodynamic therapy holds that intrapsychic conflicts, i.e. conflicts present within the psyche of the person, are the source of psychological problems, and that these conflicts arise from unfulfilled desires of childhood and unresolved childhood fears. So the fear of lizards/cockroaches would be seen not as a learned response but as the outward symptom of such an unconscious conflict. To treat it, the psychoanalyst would use free association and the reporting of dreams to bring out the client’s thoughts and feelings, and would interpret this material to the client, so that she/he can confront and resolve the conflict. The benefit sought is emotional insight: understanding the conflict intellectually, accepting it emotionally and changing one’s emotions towards it, after which the symptom (the phobia) reduces.
9 Problems Cognitive Behaviour Therapy Suits Best
Q. What kind of problems is cognitive behaviour therapy best suited for?
Answer: Cognitive Behaviour Therapy (CBT) is presently the most popular psychotherapy, and research has conclusively established it as a short and efficacious treatment for a wide range of psychological disorders, specifically named in the chapter as anxiety, depression, panic attacks and borderline personality, among others. It suits these problems because it adopts a bio-psychosocial approach: it addresses the biological aspects of distress through relaxation procedures, the psychological aspects through behaviour therapy and cognitive therapy techniques, and the social aspects through environmental manipulation. This combination makes CBT a comprehensive technique that is easy to use, applicable to a variety of disorders, and of proven efficacy.
10 In-text Activities (Activity 5.1 to 5.3)
The chapter prints three Activity boxes inside the text. All three ask you to do something yourself, so they have no single model answer; the guidance below shows what a good response contains and which part of the chapter each activity practises.
Q. A classmate or friend of yours or your favourite character in a TV serial may have recently experienced a negative or a traumatic life event (e.g., death of a loved one, break-up of an important friendship or relationship) of which you are aware. Try to put yourself in the other person’s shoes, try to experience how that person is feeling, what s/he is thinking and try to take her/his perspective of the entire situation. This will help you to understand better how that person is feeling. (Note: This exercise may be done in class, so that teachers can help students in overcoming any distress experienced.)
Answer (guidance): This activity practises empathy. Describe the event, then write how the person may be feeling and thinking, in the first person, as if it were happening to you. Check your response against the chapter’s three-way distinction: sympathy is compassion and pity for the other’s suffering without being able to feel like the other person; intellectual understanding is cold, with neither feeling nor sympathy; empathy is understanding the plight of another person and feeling like the other person, i.e. putting oneself in the other person’s shoes. The chapter says empathy enriches the therapeutic relationship and transforms it into a healing relationship.
Q. Gather information about some institutions you know which offer psychiatric/psychotherapeutic help.
Answer (guidance): Make a short table for each institution you find (for example, the psychiatry department of a government hospital or medical college in your district, or a national institute such as NIMHANS, which the chapter mentions): its name and place, who works there (psychiatrists, clinical psychologists, counsellors), and what help it offers, using the chapter’s terms: psychotherapy (behaviour, cognitive, CBT, humanistic-existential), alternative therapies such as yoga and meditation, and rehabilitation (occupational therapy, social skills training, cognitive retraining and vocational training). Note also that the chapter allows only persons trained under expert supervision to practise psychotherapy, and that ethical standards such as informed consent and confidentiality must be followed.
Q. Your friend is feeling very nervous and panicky before the examinations. S/he is pacing up and down, is unable to study and feels s/he has forgotten all that s/he has learnt. Try to help her/him to relax by inhaling (taking in a deep breath), holding it for sometime (5-10 seconds), then exhaling (releasing the breath). Ask her/him to repeat this 5-10 times. Also ask her/him to remain focused on her/his breathing. You can do the same exercise when you feel nervous.
Answer (guidance): Follow the steps exactly: inhale deeply, hold for 5-10 seconds, exhale, repeat 5-10 times, keeping attention on the breathing. The activity is a simple relaxation procedure. The chapter explains (Box 5.2) that anxiety increases the client’s arousal level and acts as an antecedent factor for faulty behaviour, such as being unable to concentrate on study, and that relaxation procedures are used to decrease anxiety levels. CBT uses relaxation procedures to address the biological side of distress, and focusing attention on the breath is also what meditation involves.
11 Box 5.1: Steps in the Formulation of a Client’s Problem
The process of psychotherapy begins by formulating the client’s problem. Clinical formulation means formulating the client’s problem in the therapeutic model being used for treatment. It has three advantages:
1. Understanding of the problem: the therapist is able to understand the full implications of the distress the client is experiencing.
2. Identification of the areas to be targeted for treatment: if a client seeks help for inability to hold a job and reports inability to face superiors, the clinical formulation in behaviour therapy states it as lack of assertiveness skills and anxiety; the target areas are inability to assert oneself and heightened anxiety.
3. Choice of techniques for treatment: this depends on the therapeutic system in which the therapist was trained, but even within it, the choice and timing of techniques and the expected outcome depend on the clinical formulation.
Clinical formulation is an ongoing process and may need reformulation as clinical insights are gained. Usually the first one or two sessions yield enough clinical material for the initial clinical formulation. It is not advisable to start psychotherapy without a clinical formulation.