Psychology · Ch 5 — Therapeutic Approaches
Type of Therapies
Type of Therapies
Therapies: A Concept-First Overview
All psychotherapies share the same goal — to reduce human distress and help people function effectively. But they differ greatly in their concepts, methods, and techniques. These differences are not random; they stem from fundamentally different answers to six key questions about psychological problems.
The three major groups of psychotherapy emerged in a clear historical sequence. Psychodynamic therapy came first, followed by behaviour therapy. The existential therapies — often called the "third force" — arrived last. Each group answers the core questions of therapy in its own distinctive way.
How the Three Therapies Differ: Six Key Parameters
1. What causes psychological problems?
Psychodynamic therapy locates the cause in intrapsychic conflicts — conflicts that exist within the person's own psyche. These are unconscious struggles between different parts of the mind.
Behaviour therapy says problems arise from faulty learning — of behaviours and of cognitions (thoughts). We learn maladaptive ways of acting and thinking, and these cause distress.
Existential therapy sees the cause in questions about the meaning of life and existence. When a person struggles with why they exist, what their purpose is, or feels their life is meaningless, psychological problems emerge.
2. How does the cause come into existence?
Psychodynamic therapy traces the cause back to childhood — specifically, to unfulfilled desires and unresolved fears from early years. These create the intrapsychic conflicts that persist into adulthood.
Behaviour therapy points to faulty conditioning patterns, faulty learning experiences, and faulty thinking and beliefs. These produce maladaptive behaviours, which in turn create psychological problems.
Existential therapy focuses on the present. It is the current experience of loneliness, alienation, and a sense that one's existence is futile that causes the problem — not past events.
3. What is the chief method of treatment?
Psychodynamic therapy uses free association (the client says whatever comes to mind) and dream reporting to bring unconscious thoughts and feelings to the surface. The therapist then interprets this material to the client, helping them confront and resolve their conflicts.
Behaviour therapy identifies faulty conditioning patterns and sets up alternate behavioural contingencies to improve behaviour. It also uses cognitive methods that challenge the client's faulty thinking patterns.
Existential therapy provides a therapeutic environment that is positive, accepting, and non-judgmental. The client talks about their problems freely, and the therapist acts as a facilitator — not an expert who provides answers. The client arrives at solutions through a process of personal growth.
4. What is the nature of the therapeutic relationship?
Psychodynamic therapy assumes the therapist understands the client's intrapsychic conflicts better than the client does. Therefore, the therapist interprets the client's thoughts and feelings to them.
Behaviour therapy assumes the therapist can discern the client's faulty behaviour and thought patterns, and also knows what the correct, adaptive patterns would be.
Both psychodynamic and behaviour therapies assume the therapist is capable of arriving at solutions to the client's problems.
Existential therapy takes the opposite view. The therapist merely provides a warm, empathic relationship in which the client feels secure enough to explore the nature and causes of their own problems — by themselves.
5. What is the chief benefit to the client?
Psychodynamic therapy values emotional insight. This is not just intellectual understanding. Emotional insight means the client:
- Understands their conflicts intellectually
- Is able to accept them emotionally
- Can change their emotions toward the conflicts
When this happens, symptoms and distress reduce as a direct consequence.
Behaviour therapy values changing faulty behaviour and thought patterns to adaptive ones. Instituting healthy behaviour patterns ensures reduction of distress and removal of symptoms.
Existential therapy (also called humanistic therapy) values personal growth — the process of gaining increasing understanding of oneself, one's aspirations, emotions, and motives.
6. What is the duration of treatment?
Classical psychoanalysis can continue for several years. However, modern versions of psychodynamic therapy are much shorter — often completed in 10–15 sessions.
Behaviour therapy, cognitive behaviour therapy, and existential therapies are all shorter, typically completed in a few months.
What All Therapies Share
Despite these differences, every psychotherapy shares a common method: it provides treatment for psychological distress through psychological means. The therapist, the therapeutic relationship, and the process of therapy itself become the agents of change that lead to the alleviation of distress.
Clinical Formulation: The First Step in Therapy
Before any therapy begins, the therapist must formulate the client's problem. Clinical formulation means stating the problem in terms of the therapeutic model being used. This is not optional — it is not advisable to start psychotherapy without a clinical formulation.
Advantages of clinical formulation
Understanding the problem — The therapist grasps the full implications of the client's distress.
Identifying target areas — The theoretical formulation clearly identifies what needs to be worked on. For example, if a client cannot hold a job because they cannot face superiors, a behaviour therapy formulation would state this as: lack of assertiveness skills and anxiety. The target areas are now clear.
Choosing techniques — The choice of techniques, their timing, and expectations of outcome all depend on the clinical formulation. The therapist's training determines the broad system, but within that, the formulation guides specific decisions.
Clinical formulation is an ongoing process. As the therapist gains new insights during therapy, formulations may need to be revised. Usually, the first one or two sessions provide enough material for an initial formulation.
Behaviour Therapy
Core premise
Behaviour therapy starts from a clear position: psychological distress arises because of faulty behaviour patterns or faulty thought patterns. The therapy focuses on the client's behaviour and thoughts in the present. The past is relevant only to understand where the faulty patterns came from — it is not activated or relived. Only the faulty patterns themselves are corrected.
Behaviour therapy is the clinical application of learning theory principles. It is not a single, unified theory applied the same way to everyone. Instead, it consists of a large set of specific techniques and interventions. The client's symptoms and clinical diagnosis guide which techniques to use. Treating phobias requires one set of techniques; treating anger outbursts requires another. A depressed client is treated differently from an anxious one.
The foundation of behaviour therapy rests on three steps:
- Formulating the dysfunctional or faulty behaviours
- Identifying the factors that reinforce and maintain these behaviours
- Devising methods to change them
Method of treatment
The therapist interviews the client (and sometimes family members) to conduct a behavioural analysis. This analysis identifies three things:
- Malfunctioning behaviours — behaviours that cause distress to the client
- Antecedent factors — the causes that predisposed the person to develop the behaviour
- Maintaining factors — the factors that keep the faulty behaviour going
Example: A young person wants to stop smoking. Behavioural analysis reveals he started smoking while preparing for annual exams. Smoking gave him relief from anxiety. So:
- The antecedent factor is the anxiety-provoking situation (exams)
- The maintaining factor is the feeling of relief that reinforces the smoking
- The client has acquired an operant response (smoking) maintained by the reinforcing value of relief from anxiety
Once the faulty behaviours are identified, a treatment package is chosen. The aim is to extinguish or eliminate the faulty behaviours and substitute them with adaptive ones. The therapist does this through:
- Antecedent operations — controlling behaviour by changing something that precedes it. For example, if a child won't eat dinner, an establishing operation would be to reduce the quantity of food served at tea time. This increases hunger at dinner, which increases the reinforcing value of food at dinner.
- Consequent operations — controlling behaviour through what follows it. Praising the child when they eat properly encourages that behaviour.
Behavioural techniques
A range of techniques is available. Their principles are:
- Reduce the client's arousal level
- Alter behaviour through classical or operant conditioning using different contingencies of reinforcement
- Use vicarious learning (learning by observing others) when needed
Relaxation procedures
Anxiety increases the client's arousal level and acts as an antecedent factor for faulty behaviour. The client may smoke to decrease anxiety, eat excessively, or be unable to concentrate. Reducing anxiety therefore decreases these unwanted behaviours.
Progressive muscular relaxation: The client is taught to contract individual muscle groups to become aware of what tension feels like. After tensing a muscle group (like the forearm), the client is asked to let go of the tension. With repeated practice, the client learns to relax all the muscles of the body. Meditation is another method for inducing relaxation.
Negative reinforcement and aversive conditioning
Negative reinforcement occurs when responses that help an organism get rid of painful stimuli, or avoid or escape from them, are reinforced. For example, we learn to put on warm clothes or use heaters to avoid unpleasant cold. We learn to move away from dangerous stimuli because doing so provides negative reinforcement.
Aversive conditioning involves repeatedly pairing an undesired response with an aversive consequence. For example, an alcoholic is given a mild electric shock while smelling alcohol. With repeated pairings, the smell of alcohol becomes aversive because it is associated with the pain of the shock. The person then gives up alcohol.
Positive reinforcement and token economy
If an adaptive behaviour occurs too rarely, positive reinforcement is used to increase it. For example, if a child does not do homework regularly, the mother might prepare the child's favourite dish whenever homework is done at the appointed time. The positive reinforcement of food increases the homework behaviour.
In institutional settings, patients or children can be given a token as a reward every time a wanted behaviour occurs. Tokens are collected and exchanged for a reward — an outing for a patient, a treat for a child. This is called token economy.
Differential reinforcement
Unwanted behaviour can be reduced and wanted behaviour increased simultaneously. One method is to use positive reinforcement for the wanted behaviour and negative reinforcement for the unwanted behaviour together. Another method — less painful and equally effective — is to positively reinforce the wanted behaviour and ignore the unwanted behaviour.
Example: A girl sulks and cries when she is not taken to the cinema. The parent is instructed to take her only if she does not cry and sulk, and to ignore her when she does cry and sulk. The polite asking increases; the crying and sulking decreases.
Systematic desensitisation
This technique, introduced by Wolpe, is used for treating phobias or irrational fears. The process:
- The therapist interviews the client to identify fear-provoking situations
- Together, therapist and client prepare a hierarchy of anxiety-provoking stimuli, with the least anxiety-provoking at the bottom
- The therapist relaxes the client
- The client is asked to think about the least anxiety-provoking situation
- If the slightest tension is felt, the client stops imagining the fearful scene
- Over sessions, the client is able to imagine more severe fear-provoking situations while maintaining relaxation
The principle of reciprocal inhibition operates here: when two mutually opposing forces are present at the same time, the weaker force is inhibited. The relaxation response is built up first, then a mildly anxiety-provoking scene is imagined. The relaxation overcomes the anxiety. The client can tolerate progressively greater levels of anxiety because of their relaxed state.
Modelling
In modelling, the client learns to behave in a certain way by observing the behaviour of a role model — often the therapist, who initially acts as the model. Vicarious learning (learning by observing others) is used. Through a process of rewarding small changes in behaviour, the client gradually acquires the behaviour of the model.
The skill of the behaviour therapist lies in conducting an accurate behavioural analysis and building a treatment package with the appropriate techniques from this wide variety of options.
Cognitive Therapy
Cognitive therapies locate the cause of psychological distress in irrational thoughts and beliefs.