Psychotherapy

Wolberg (1988) definition – Psychotherapy is the treatment, by psychological means, of

problems of an emotional nature in which a trained person deliberately establishes a
professional relationship with the patient with the object of –

 Removing, modifying or retarding existing symptoms

 Mediating disturbed patterns of behaviour

 Promoting positive personality growth and development

Differences with psychoeducation and counselling

 Psychoeducation – knowledge about etiology, course and prognosis of a condition

 Counselling – more specific than therapy, dealing with a specific life situation,
coping, environmental manipulation

Major approaches

 Supportive

 Re-educative

 Re-constructive

Major schools of individual psychotherapy

 Psychoanalytic

 Behavioural and cognitive behavioural

 Existential and humanistic

 Other experiential

The various approaches to emotional illness involve many affiliated fields.

In the main, the following avenues are pursued:

1. Organic-physiological regimens that, rooted in the soil of biology, are strictly

speaking not psychotherapeutic.
2. Behavioral-conditioning techniques, psychologically oriented, that deal with the
effects of conflict and depend on relearning and the retraining of responses without
concerning themselves too much with conflictual sources.
3. Supportive relationship tactics, sociologically based, that draw upon factors that are
operative in any “helping process.”
4. Dynamic-reconstructive methodologies, psychologically and sociologically inspired,
that focus on insight, delineating the origins of conflict, its effect on intrapsychic
 functioning, its manifestations in character structure, and its impact on problem
solving and other vital behavioral activities.
5. Philosophic-persuasive ideologies aimed at alteration of values and meaning systems,
toward the development of more adaptive ways of approaching life’s burdens.

In actual practice there is often a fusion of approaches, although the followers of specific
schools may refuse to admit.

Practitioners and theorists in the 1950s and 1960s who were frustrated by the apparent (and,
in some respects, actual) lack of rigor in the field were inspired by Gordon Paul’s (1967) call
to find “what treatment by whom is most effective for this individual with that specific
problem, and under what specific set of circumstances” (p. 111). As a result, a line of
research was built on the belief that effective therapies must have similar steps that, if
identified, quantified, and replicated, would reliably produce the same effective results,
regardless of who the client or the therapist was. These researchers felt that the way to
accomplish this was to break down a particular therapeutic approach into its constituent parts,
so that any practitioner could learn it and faithfully reproduce the treatment with a client. And
so we saw the birth of treatment “manuals,” providing a “how-to” methodology for clinicians
to follow, and establishing guidelines for specific treatments and techniques, and their
implementation. These manuals are typically derived from studies that carefully select
patients who meet rigid criteria for the establishment of the particular diagnosis from the
DSM-IV-TR for the treatment that is under study. Patients are evaluated periodically, and if
there is sufficient (i.e., statistically significant) improvement with a majority of the clients,
then the treatment is considered “empirically supported” (i.e., evidenced based). The pinnacle
of this search was the development of empirically supported treatment (EST; also called
empirically validated treatment [EVT] or EBPP).

Researchers found evidence (as mentioned above) that psychotherapy in general was
beneficial and effective. Research even demonstrated that there were some therapeutic
approaches that seemed to work better with certain diagnoses (e.g., behaviour therapy with
phobias, and cognitive therapy with depression). But the search for one therapy that might
prove superior to others in all cases of a particular diagnosis has not been the unqualified
success for which researchers had hoped.

When investigators observed research findings on effectiveness across vastly different

settings and with vastly different populations, they found that clients seemed to improve at
roughly the same rate (Miller, 2004; Prochaska, 1999). This ran counter to conventional
wisdom, because the approaches were so widely varied, ranging from psychodynamic, to
behavioural, to systems theory. Furthermore, they concluded that the way to best achieve
(and later train others to achieve) effectiveness in therapy was to see what factors comprised
effective therapeutic alliance.

At the turn of the 21st century, some 500 different theoretical approaches to psychotherapy
could be identified, with the majority representing attempts at some kind of integration
(Miller et al., 2005; Norcross, 2002). Different “models” of psychotherapy have been derived
from a synthesis of theories, techniques, and formats, responses and integrate them into a
single coherent approach.

The attempt to create a single unified or integrated theoretical approach to psychotherapy,

like the attempt to create a manual of treatment strategies, fails to take into account the
therapist’s personal talents, personality traits, personal styles, and theoretical-philosophical
preferences. Though the one-size-fits-all approach of integration may tantalize developing
practitioners with the idea that a grand unified theory can be adopted and easily implemented,
the result is that the clinician then has very little freedom to adopt a perspective that is in
harmony with his or her view of the world. Instead, with theoretical integration, every
therapist must adhere to an a priori way of looking at the world of psychotherapy.

The common factors or convergence approach (Messer & Warren, 1995) also suggests that
there is considerable overlap among the various theories and systems of psychotherapy. But
rather than seeking to combine theories, those who subscribe to the convergence movement
seek to identify the universal elements of the change process that are common to all effective
systems of psychotherapy regardless of the different languages they use to describe what they
do.

Significant Factors/Variables in psychotherapy

Lambert and Barley (2002) cited and summarized numerous studies over the last 40 years
that have provided interesting consistent clues regarding therapists’ contributions to
successful therapeutic outcomes. In particular, they not surprisingly concluded that therapists
who exhibit more positive behaviours—warmth, understanding, and affirmation—and fewer
negative behaviours—belittling, neglecting, ignoring, and attacking—were consistent
predictors of positive outcome.

Furthermore, they emphasized the vital importance of having a strong therapeutic alliance,
focusing on the therapeutic relationship and making discussions about it a regular part of
dialogue in therapy, and being willing to spend time on complicated issues with a sense of
optimism, which are all positive characteristics of successful therapies.
Last, they concluded, therapist credibility, skill, empathic understanding and affirmation of
the patient, along with the ability to engage with the patient to focus on the patient’s
problems, and to direct the patient’s attention to the patient’s affective experience, were more
highly related to successful treatment.

When investigators observed research findings on effectiveness across vastly different

settings and with vastly different populations, they found that clients seemed to improve at
roughly the same rate (Miller, 2004; Prochaska, 1999). This ran counter to conventional
wisdom, because the approaches were so widely varied, ranging from psychodynamic, to
behavioral, to systems theory.
Furthermore, they concluded that the way to best achieve (and later train others to achieve)
effectiveness in therapy was to see what factors comprised effective therapeutic responses
and integrate them into a single coherent approach.
At the outset it is necessary to recognize that no psychotherapeutic method exists today that is
applicable to all patients or relevant to the styles of all therapists. As disparate as the various
approaches to psychotherapy may seem, their impact on the patient is often registered in
similar ways.

First, they offer a unique kind of interpersonal relationship in which one feels accepted for
what one is and where judgments concerning attitudes and behavior do not agree with
habitual expectations.

Second, there is an explicit and implicit reinforcement of selected responses with the object
of overcoming important behavioral deficits and of extinguishing maladaptive habit patterns.

Third, there are direct or indirect attempts made at cognitive restructuring, through various
instrumentalities, such as (1) persuasive arguments (2) the exploration of conscious and
unconscious conflicts aimed at the inculcation of insight, and (3) the provision of a corrective
behavioral and emotional experience within the matrix of the patient-therapist interaction.

Irrespective of behavioral parameters that purportedly are selected for inquiry and
rectification, the patient will respond to the therapeutic interventions being utilized in
accordance with personal needs and readiness for change.

These facts have fathered a common idea among professionals that therapists of different
theoretical orientations do essentially the same things. The patient presents a problem; an
attempt is made to establish a meaningful relationship; some formulation is presented to the
patient as a working hypothesis; and special procedures are implemented to enhance the
patient’s mastery and eliminate disruptive elements in adjustment.

If this be true, then techniques are merely forms of communication secondary to a host of
transactional processes that draw from many biological, intrapsychic, and interpersonal
vectors.

The climate of successful therapy depends on a number of factors that are operative in all

good helping situations. These include the following:

1. Hope. Patients approach the ministrations of the therapist with assured expectancy. A
sanguine anticipation of success is present. Therapists have confidence in their methods and
theories.

2.Trust. Patients see their therapists as sincere, honest, reliable, guileless, trustworthy,
undeceitful, unaffected, straightforward, and authentic beings. Therapists display respect for
their patient in spite of the latter’s pathological behavior. Therapists also reveal their own
genuineness.

3.Freedom to respond. Patients permit themselves to think, feel, and act without restraint.
This permits them to verbalize freely and to unburden themselves. Therapists encourage
freedom in reactivity. This sponsors emotional catharsis.
4. Faith. Patients have a conviction that therapists possess the percipience, sensitivity,
wisdom, experience, skill, and ingenuity to understand basic presenting problems and
difficulties and to know what to do about them. Therapists convey assuredness, positiveness,
and empathic understanding. This facilitates the suggestive factor.

5. Liking. Patients conceive of their therapists as empathic individuals who relate to them
personally, and warmly; in turn, therapists feel a non-possessive warmth toward the patients.
This releases dynamic ingredients present in all human encounters (dyadic and larger groups)
that constructively influence attitude change.

Specificity Hypothesis:

 Initially, the specificity hypothesis focussed on the therapeutic models as a whole,

seeking to establish the relative superiority of one therapy modality over another in
treating a specific disorder.

 Specific Ingredients - Accepting that most psychotherapies are effective, researchers

started looking for specific ingredients important to each model. This has led to
component analysis of the various models of psychotherapy. In these studies, the
treatment in question is divided into major components and the unique contribution of
each component is teased out using various research and statistical designs.

Common Factor approach:

Smith, Glass and Miller (1980) and Wampold (2001)

 Common mediators of change

 Common mechanisms of change

Common mediators of change

1. Client

2. Therapist

3. Therapeutic relationship

4. Extra-therapeutic factors

5. Expectancy

Frank and Frank (1991) argued that all psychotherapies shared four basic components:

(a) An emotionally charged confiding relationship with a helping person;

(b) A setting that is judged to be therapeutic, in which the client believes the
professional can be trusted to provide help on his or her behalf;
 (c) A therapist who offers a credible rationale or plausible theoretical scheme for
understanding the patient's symptoms; and

(d) A therapist who offers a credible ritual or procedure for addressing the symptoms

Frank and Frank (1991) also discussed six elements that were common to the rituals and
procedures just mentioned: They are -

(a) The therapist combats the client's demoralization and alienation by establishing a strong
relationship;

(b) The therapist links hope for improvement to the process of therapy, which heightens the
patient's expectation;

(c) The therapist offers new learning experiences;

(d) The client's emotions are aroused and reprocessed;

(e) The therapist facilitates a sense of mastery or self-efficacy; and

(f) The therapist offers opportunities for the client to practice new behaviours.

Till date, Karasu (1986) has offered one of the most influential and parsimonious approach to
integrating specific techniques used by different theoretical models within a single theoretical
framework. He argued that non-specific change processes could be subsumed under three
dimensions: Affective Experiencing, Cognitive Mastery, and Behavioural Regulation.

Emotional experiencing - Heightened arousal makes patients more receptive to suggestion

and therefore more willing to change attitudes than low arousal conditions.

Attitude changes occur when therapists facilitate clients’ regulating or experiencing of

emotions and making emotional connections.

Cognitive mastery: those aspects of the treatment

 which use reason and meaning (conscious or unconscious) over affect as their primary
therapeutic tool

 which attempt to achieve their effects through the acquisition and integration of new
perceptions, thinking patterns and / or self awareness.

 Therapists facilitate cognitive mastery by offering reframes, interpretations,

explanations, or rationales. They also offer information.

Behavioural regulation: Behavioural regulations serve therapeutic functions of

 offering practical and expedient mastery of specified problems,

 reinforcing learning through repetition and practice of new behaviours, and

 providing tangible application of change.

Karasu posited that Behaviour Modification, Psychoanalysis and even Rogers’ so called Non-
Directive Therapy incorporate behavioural regulation.

Family therapists Duncan, Miller, and colleagues (Hubble et al., 1999; Miller et al., 1997)
have proposed a model for the common factors (Blow & Sprenkle, 2001). Their four factors
were:

(a) Client and extra-therapeutic factors (said to account for 40% of change),

(b) relationship factors (30%),

(c) model/technique factors (15%), and

(d) placebo, hope, and expectancy factors (15%).

Wampold (2001) presents evidence - at most 8% of the outcome variance in psychotherapy is

due to the unique contributions of models-even including popular models like CBT. General
factors shared by all successful psychotherapies accounted for about 70% of outcome
variance and about 22% of the variance was unexplained (Wampold, 2001).

Morawetz (2007) - most important client factors

 client’s personal strengths and weaknesses,

 motivation,

 talents,

 values,

 skills,

 experiences,

 perseverance,

 resources, beliefs,

 attitude towards the value of counselling,

 social supports,

 willingness to take a risk, and potential for change.

 client’s capacity to relate,

 ego strength

 ability to identify a focal problem to be important factors affecting outcome.

 Nature and severity of disturbance

  motivation of the client

 positive life change

 nature and quality of social support

Hope and Expectancy:

Hopeful individuals - psychologically more resilient

 Increased life expectancies

 Higher positive mental health, personal adjustment, life satisfaction and sense of
meaning in life

 They recover from illness and injury more effectively

 Manifest less depression and anxiety

Hopeful individuals have been found to fare better in counselling and psychotherapy.
They tend to

 persevere when barriers arise (Scheier & Carver, 1992)

 are successful in finding “benefits” from adversity

 improve the most with counselling

 are more effective problem solvers

 adapt when circumstances warrant it

Therapeutic alliance:

 Freud – transference/ countertransference

 Greenson – real and transference relationship

 Rogers

 Behaviourists - initial and later positions

 Bordin (1979) – concept of alliance – consists of three interlocking components:

 Bonds (the affective quality of the client-therapist relationship that includes

dimensions such as trust, care and involvement);

 tasks (agreement or consensus on the major activities in therapy and the extent to
which the client finds them credible); and

 goals (consensus on the short term and long-term outcome expectations between the
therapist and the client).
 With regard to the components of the therapeutic relationship –

 Therapist’s empathy

 Goal consensus and collaboration

 Therapists’ positive regard

 Therapist congruence

 Therapist’s validation

Both the therapist and the client characteristics appear to contribute to the therapeutic
alliance.

Therapist – less self-directed hostility in the therapist, more perceived social

support, and comfort with closeness led to a stronger bond component of the therapeutic
alliance.

therapist’s interpersonal skills were positively associated with client involvement as

defined by cooperation, disclosure and expression of affect.

countertransference management - The overall association of Countertransference

management to treatment outcome was significant and large

 Patient’s pre-treatment interpersonal functioning - friendly-submissive

interpersonal problems - positively related to the development of aspects of the
alliance while hostile-dominant problems in the patient - negatively related to the
development of aspects of the alliance early in short-term cognitive therapy.

 Patients with higher capability to form the working alliance reached the best
psychotherapy outcomes.

 Clients’ pre-treatment expectations of improvement have been found to lead to a

better therapeutic alliance early in therapy

According to Krause, Lutz and Saunders (2007) ‘…forms of psychotherapy are not
separable in practice from the therapists who apply them, so apparent differences in
effectiveness between forms of treatment are always confounded by differences in
effectiveness between therapists.......... what should primarily be given preference in
practice are not treatments empirically certified on the basis of their results in randomised
clinical trials, but psychotherapists empirically certified to practice on the basis of their
results in actual practice.’

Bellows (2007), in a qualitative study on therapists who had previously undergone

therapy, found that theparticipants whose personal therapy most influenced their clinical
practice were more likely

 to view their treatment as promoting psychological change,

 to value their former therapist as a professional role model,

 think about their former therapist when they were unsure about what to do in a
clinical situation

 to believe that psychotherapy should focus on the working relationship between

patient and therapist.

 therapists’ personality characteristics and emotional skills, the findings provide

more unequivocal support for the importance of the therapist factors.

More effective therapists displayed -

 more positive behaviours (e.g., warmth and alliance),

 fewer negative behaviours (e.g., attacking and blaming), and

 more self-criticism than less effective therapists.

Therapists with more secure attachment styles have better outcomes

On the dimension of religiosity, research findings suggest that religious people may
anticipate negative experiences with secular or non-religious fearing that their values may
be undermined, or that they would be misunderstood or misdiagnosed in some way

The literature from expert clinicians, theoreticians, and researchers has repeatedly
reinforced the development, importance, use, and efficacy of the common or convergence
factors.

These convergence factors can be found at the heart of all successful therapy and
represent what master practitioners pay attention to.

They are as follows: 1. Connecting with and engaging the client 2. Assessing and
accessing the client’s motivations, goals, and strengths 3. Building and maintaining the
therapeutic relationship—an “alliance” with the client 4. Understanding a client’s
cognitive schemas 5. Addressing and managing a client’s emotional states 6.
Understanding and addressing client ambivalence about change 7. Understanding and
using nonlinear-paradoxical thought processes and intervention in treatment.

Skovholt and Jennings (2004) identified these cognitive characteristics of master

therapists:

• They are voracious learners. • Accumulated experience has become a continually

accessed, major resource for them. • They value cognitive complexity and the ambiguity
of the human condition.

In other words, master therapists delight in the pursuit of knowledge, have a healthy sense
of curiosity, have the intellectual sophistication to handle complex situations, and
understand that ambiguity in human problem solving is normative, not aberrant.
 According to Jennings and Skovholt (1999, in the emotional domain, expert therapists
access and use the following behaviours:

• They appear to have emotional receptivity, defined as being self-aware, reflective, non
defensive, and open to feedback. • They seem to be mentally healthy and mature
individuals who attend to their own emotional well-being. • They are aware of how their
emotional health affects the quality of their work. Hence, master therapists are
nonreactive (e.g., non-defensive, calm, etc.) in the face of a client’s strong emotional
reactions, can appropriately use their emotional impulses to illuminate the therapeutic
discourse, and have sufficient capacity to soothe themselves in the moment when their
emotions are stirred up.

In the relational domain (in terms of how therapists relate to others), expert therapists are
characterized as follows: • They possess strong relationship skills. • They believe that the
foundation for therapeutic change is a strong working alliance. • They appear to be
experts at using their exceptional relationship skills in therapy. Briefly, this means that
master therapists are keenly attuned to the relationship dimension with a client, and have
the ability to perceive how much change they can expect the client to tolerate before there
is a rupture in the therapeutic alliance. Clearly, all of these are crucial in employing the
convergence factors and being effective with clients

What is ethics?

Historically, the term ‘ethics’ comes from Greek ‘ethos’ which means the customs, habits and
mores of people. ‘Morality’ is derived from Latin mos, moris which denotes basically the
same; it was introduced by Cicero as an equivalent to the Greek ethos

Morality means the customs, the special do-s and don't-s that are shared and widely accepted
as standard in a society or community of people.

Ethics on the other hand is the philosophical reflection upon these rules and ways of living
together, the customs and habits of individuals, groups or mankind as such. Ethics are self
regulatory guidelines for making decisions and defining professions. By establishing ethical
codes; professional organizations, maintain integrity of the profession, define the expected
conduct of members, and protect the welfare of subjects and clients. Moreover, ethical codes
give professionals direction when confronting ethical dilemmas.

In health care, ethical concepts derived from normative theories. These theories assist a
mental health profession to guide in decision making.
There are three sub branches of ethics:

1.Descriptive ethics -aims at empirically and precisely mapping existing morality or

moralities within communities and is therefore linked to the social sciences.
2. Metaethics- is a relatively new discipline in the ethical arena and its definition is the most
blurred of all. The Greek ‘meta’ means after or beyond and indicates that the object of
metaethical studies is morality and ethics itself.

3.Normative ethics- means the methodological reflection upon morality tackling its critique
and its rationale. Norms and standards for acting and conduct are being set up or tore down,
and argued for or against. When “ethics” is talked about in a common sense then we are
talking about this general normative ethics.

In normative ethics there are different theories as to how criteria of moral conduct should be
defined.

NORMATIVE ETHICAL THEORIES:

1. Authority based Theories: it is faith based, such as Christian, Muslim, Hindu ethics.
They could also be purely ideological, such as these based on the writings of Karl
Marx, (1818-1883) or on capitalism. Essentially, authority-based theories determine
the right thing to be based on what some authority has said.
2. Natural law theory: the key idea behind this is that nature is ordered rationally and
providentially. The right thing to do is that which is in accord with the providentially
ordered nature of the world.
3. Teleological theory: consider the ethics of a decision to be dependent on the
consequences of the action.
4. Deontological theory: this theory can be traced back to Immanuel Kant (1724-1804).
The term ‘Deon’ is from the greek means duty. Thus, deontology could be called the
science of determining our duties.
 Egoistic theories: these theories argue that what is right is that which maximizes a
person’s self interests
PRINCIPLES OF ETHICS:
Principle A: BENEFICENCE AND NONMALIFICENCE: Clinicians strive to benefit
those with whom they work and take care to do no harm. In their professional actions,
clinicians seek to safeguard the welfare and rights of those with whom they interact
professionally and other affected persons, and the welfare of animal subjects of
research. When conflicts occur among colleagues’ obligations or concerns, they
attempt to resolve these conflicts in a responsible fashion that avoids or minimizes
harm.

Principle B: FIDELTY AND RESPONSIBILITY: Clinicians establish relationships

of trust with those with whom they work. They are aware of their professional and
scientific responsibilities to society and to the specific communities in which they
work. Clinicians uphold professional standards of conduct, clarify their professional
roles and obligations, accept appropriate responsibility for their behaviour, and seek
to manage conflicts of interest that could lead to exploitation or harm.
Principle C: INTEGRETY: clinicians seek to promote accuracy, honesty, and
truthfulness in the science, teaching, and practice of psychology. In these activities
psychologists do not steal, cheat, or engage in fraud, subterfuge, or intentional
misrepresentation of fact. Clinicians strive to keep their promises and to avoid unwise
or unclear commitments.

Principle D: JUSTICE: Clinicians recognize that fairness and justice entitle all
persons to access to and benefit from the contributions of psychology and to equal
quality in the processes, procedures, and services being conducted by them.

Principle E: RESPECT FOR PEOPLE’S RIGHTS AND DIGNITY: Clinicians

respect the dignity and worth of all people, and the rights of individuals to privacy,
confidentiality, and self-determination. They are aware that special safeguards may be
necessary to protect the rights and welfare of persons or communities whose
vulnerabilities impair autonomous decision making. They are aware of and respect
cultural, individual, and role differences, including those based on age, gender, gender
identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability,
language, and socioeconomic status, and consider these factors when working with
members of such groups.