PSYCHOTHERAPEUTIC METHODS (MPCE-013)

TUTOR MARKED ASSIGNMENT (TMA)

Course Code: MPCE-013

Assignment Code: MPCE 013/ASST/TMA/2024-25
Marks: 100

NOTE: All questions are compulsory.

SECTION – A

Answer the following questions in 1000 words each. 3 x 15 = 45 marks

1. Explain solution focused therapy in detail including the interventions used in it.
Solution Focused Therapy (SFT) is a type of brief therapy that focuses on building solutions rather than
solving problems. It emphasises the future rather than the past or present and helps clients use their strengths
to find solutions to their problems.
Core Principles of SFT
 Solution-building focus: SFT concentrates on developing solutions, not on analyzing problems.
 Existing solutions: The approach assumes that clients already have the solutions they need, and the
therapist's role is to help them recognise these.
 Small changes lead to larger changes: The idea that small positive changes can create more
significant overall improvements.
 Client-defined solutions: Solutions are not necessarily related to the identified problem but come
from the client's own understanding.
 Conversational approach: The therapist uses specific conversational techniques to guide clients
toward building their own solutions.
Therapeutic Process
 Collaboration: The therapist and client work together to define what the client wants to achieve.
 Client expertise: The client is seen as an expert in their own life, and the therapist learns from the
client’s perspective.
 Focus on strengths: The therapist helps clients identify and utilise their strengths and competencies.
 Exceptions to the problem: Therapists help clients recognise when the problem is not present or is
being managed well.
 Clear goals: Therapists help clients focus on solutions in specific, clear terms.
 Client-led pace: The number of sessions is not fixed; the client decides if and when a further session
is needed.
Interventions in SFT
 Pre-session change: The therapist asks the client to notice any changes that occur between the time
of making the appointment and the first session, using these changes as a starting point.
 Exception-seeking questions: The therapist helps the client identify times when the problem is not
present or is being managed better and what they did to make that happen.
 The miracle question: This is a future-oriented question which aims to help the client envision what
their life will be like when the problem is solved. A standard formula for the miracle question is
used.
 Scaling questions: These are used to explore the client’s achievements and goals of therapy.
 Reframing: The therapist helps the client to see the problem in different ways that may lead to
solutions.
  Compliments: The therapist gives genuine compliments to the client on helpful things that the client
is doing, thinking or saying.
 Tasks: The therapist may give the client a task to perform between sessions. For example, clients
may be asked to notice things that they would like to see continue.
Therapist's Role
 Facilitator: The therapist helps the client move in the direction they want.
 Learning position: The therapist adopts a "one-down position," encouraging the client to teach them
about their perspective.
 Collaborator: The therapist shares expertise while respecting the client’s knowledge of their own
life.
 Positive and accepting: The therapist offers a warm and accepting environment.
Key Differences from Traditional Approaches
 SFT focuses on solutions rather than problems, unlike traditional therapy that may focus on
exploring feelings, behaviors and past experiences.
 SFT does not focus on the past, but the present and future.
 SFT uses client's strengths and resources, rather than focusing on past failings.
Compatibility with Other Therapies
 SFT can be used alongside other therapies, encouraging clients to continue with treatments that are
working for them.
 If traditional treatments have been helpful, clients are encouraged to continue with them, thus SFT
can be used as a part of a comprehensive treatment program.
Appropriate Target Populations
 SFT is useful as a primary treatment for many individuals in outpatient therapy.
 It can be a part of a more comprehensive program for clients with severe issues or unstable
situations.
 SFT can be effective in treating issues such as drug and alcohol misuse and adolescent behavioral
problems.
Summary SFT is a brief therapy that emphasizes client strengths and resources. It uses specific
conversational techniques and interventions like the miracle question to help clients create solutions to their
problems by focusing on the future, rather than dwelling on past or present problems.

2. Describe the steps in cognitive behavior therapy. Explain the cognitive and
behavioural techniques used in it.
Cognitive Behaviour Therapy (CBT) is a type of psychotherapy that operates on the principle that emotions
and behaviours are largely influenced by cognitive processes, and that these processes can be modified to
change how someone feels and behaves. It is a structured and collaborative approach that aims to empower
clients by teaching them to be their own therapists.
Steps in Cognitive Behaviour Therapy: The process of CBT generally involves several key steps:
 Engage Client: Building a relationship with the client is the first step. This involves creating a
warm, empathic, and respectful environment. The therapist will also look for any secondary
disturbances like self-doubt or anxiety the client might have about seeking help.
 Assess the Problem, Person and Situation: A thorough assessment is conducted to understand the
client's specific problems, their personal history, and current circumstances. This assessment may
include identifying any non-psychological factors, such as physical conditions, medications,
substance abuse, or lifestyle factors that may be contributing to the problem.
 Prepare the Client for Therapy: This step includes clarifying treatment goals, assessing the
client’s motivation for change, introducing the basics of CBT (including the biopsychosocial model
of causation), discussing the approaches to be used, and developing a therapy contract.
 Implement the Treatment Programme: This is the main phase of therapy, where various activities
and techniques are used. This may include techniques to uncover beliefs, and to dispute and change
any irrational beliefs by replacing them with more rational alternatives.
  Evaluate Progress: Throughout the therapy, progress is continuously evaluated to ensure that the
treatment is effective and that goals are being met.
 Prepare the Client for Termination: The final step involves preparing the client for the end of
therapy, ensuring they have the tools and strategies to maintain their progress and manage future
challenges.
Cognitive Techniques Used in CBT: CBT uses a variety of cognitive techniques aimed at changing
dysfunctional thought patterns. Some of these include:
 Self-monitoring: Clients are instructed to observe and record their own emotional and behavioural
reactions throughout their daily lives. This helps identify patterns and triggers and to select a target
of monitoring based on the client’s goals.
 Identifying dysfunctional thinking: The ABC model is used to uncover the client's beliefs. This
involves noting an activating event (A), the client's belief about the event (B), and the resulting
emotional and behavioural consequences (C). The client is asked, “What was I telling myself about
‘A’, to feel and behave the way I did at ‘C’?”.
 Disputing and changing irrational beliefs: The ABC model is extended to include 'D' (Disputing
irrational beliefs), 'E' (the desired new Effect - new ways of feeling and behaving), and 'F' (Further
Action for the client to take).
 Rational Self-Analysis: Clients write down an emotional episode in a structured fashion, to help
them understand their irrational beliefs and replace them with more rational alternatives.
 Devil's Advocate: The therapist role-plays adopting the client’s dysfunctional belief and argues for
it, while the client tries to ‘convince’ the therapist that the belief is dysfunctional.
 Cognitive restructuring: This involves challenging negative thoughts, thinking errors, and
considering alternative viewpoints.
Behavioural Techniques Used in CBT: CBT also incorporates a range of behavioural techniques aimed at
modifying actions and responses. These techniques include:
 Exposure: Clients are deliberately exposed to feared situations they would normally avoid. This is
done in a planned way, using cognitive and other coping skills. This helps clients test the validity of
their fears, learn that catastrophe does not ensue, and develop confidence in their ability to cope.
 Activity Scheduling: This involves planning and scheduling activities that can promote positive
mood and behaviour.
 Postponing gratification: This is used to combat low frustration tolerance, by deliberately delaying
smoking, eating sweets, or using alcohol.
 Skills training: Clients learn skills such as relaxation and social skills.
 Homework: Clients are often given homework assignments to practice what they have learned in
sessions. This may include self-help exercises such as thought recording and experiential activities.
Treatment Principles of CBT CBT operates on certain key principles:
 Empowerment: The goal is to give clients the freedom to choose their emotions, behaviours, and
lifestyle, and to develop methods for self-observation and personal change.
 Realistic thinking: CBT promotes realistic thoughts, emotions, and behaviours that are in
proportion to events and circumstances, rather than focusing on positive thinking.
 Education and collaboration: Clients are taught the therapy and how to apply it to themselves, with
the therapist providing training and support.
 Focus on the present: CBT is task oriented and focuses on problem-solving in the present, with less
emphasis on background and historical information.
 Empiricism: CBT is based on research and the principles of logic and empiricism, encouraging
scientific rather than 'magical' ways of thinking.
 Lasting change: The focus is on profound and lasting change in the underlying belief system, rather
than just eliminating symptoms.
CBT is considered a brief, time-limited therapy, typically involving 5 to 30 sessions over 1 to 18 months. It
aims to leave clients with self-help techniques that enable them to cope in the long-term future. The
relationship between the therapist and client is seen as important, with the therapist showing empathy,
acceptance, and encouragement. The therapist is careful to avoid creating dependency.

3. Explain Roger’s client centered therapy.

Roger's client-centered therapy, also known as person-centered therapy or non-directive counselling, is an
approach to counselling founded by Carl Rogers that aims to promote human psychological growth. This
approach can be applied in various settings where a helper seeks to facilitate personal development. The
client-centered approach is based on a philosophy of human nature, rather than specific techniques, and
emphasises the therapeutic relationship.
Core Principles
 Humanistic Approach: Client-centered therapy views human beings as inherently good, with a
natural desire to become fully functioning individuals. It has faith in human nature, believing people
will flourish if allowed to develop freely.
 Self-Actualisation: The core belief is that people innately move towards self-actualisation and
health, possessing the inner resources to move themselves in positive directions.
 Trust in the client: Clients are seen as the best resource for their own growth and change, capable
of self-directed growth if involved in a respectful and trusting therapeutic relationship.
 Phenomenological focus: The therapy focuses on the client’s perception of self and the world,
providing a space where they are listened to without evaluation or judgement.
Goals of Client-Centered Therapy
 Safe Environment: To provide a safe and caring environment for clients to get in touch with their
essential positive elements that may be hidden or distorted.
 Increased Self-Esteem: To increase self-esteem and openness to experience.
 Congruence: To foster closer agreement between the client’s idealised and actual selves, reducing
distortion and leading to greater trust in their own reactions.
 Self-understanding: To promote better self-understanding, and lower levels of defensiveness, guilt,
and insecurity.
 Positive Relationships: To create more positive and comfortable relationships with others.
 Emotional Expression: To increase the ability to experience and express feelings at the moment
they occur.
 Self-Directed Growth: To assist clients in their growth so they can better cope with current and
future problems.
 Internal Evaluation: To develop an internal source of evaluation, where individuals are driven by
productive, flexible decision making rather than stereotypes.
 Client autonomy: The therapist does not choose specific goals for the client, as the responsibility
for the direction of therapy is on the client.
The Counselling Process
 Core Conditions: The counsellor provides conditions that encourage the client’s natural tendency
toward personal growth. These core conditions include empathy, unconditional positive regard, and
congruence or genuineness.
o Empathy: The counsellor’s ability to understand the client at a deep level, staying within the
client’s internal frame of reference. The counsellor listens carefully to verbal and nonverbal
cues and communicates this understanding to the client.
o Unconditional Positive Regard: The counsellor conveys unconditional acceptance and
warmth towards clients, valuing them even when they experience themselves as negative,
bad, frightened or abnormal.
o Genuineness and Congruence: The counsellor is real and true in the relationship,
embodying the attitudinal quality of genuineness, empathic understanding and unconditional
positive regard towards the client.
 Therapeutic Relationship: The counselling relationship is based on respect for the client,
establishing an empathic bond and the willingness of the counsellor to be open and genuine.
  Focus on the Present: The therapy focuses most heavily on the present. Reactions between client
and counsellor can be immediately verified and explored.
 Active Listening: The counsellor uses active listening, demonstrating empathy through attentive and
interactive skills, facing the client, leaning towards them, and making eye contact.
 Reflection: The counsellor responds to clients through reflection of feelings and content,
paraphrasing and summarising, asking open questions, and responding appropriately to silence and
non-verbal communication. The therapist recognises and reflects the client's words and feelings, and
conveys feelings that the client might not even recognise.
 Self-Disclosure: While congruence is necessary, it is different from self-disclosure. Limited self-
disclosure by the therapist can be useful, as it allows clients to compare their views with another
person whom they trust, offering a chance to revise their views.
Therapist's Role
 Facilitator: The counsellor acts as a facilitator and reflector, aiding the client’s self-understanding
and clarifying expressed feelings and attitudes.
 Non-directive: The therapist takes a non-directive role, trusting that the client has the potential to
solve their own problems.
 Instrument of Change: Therapists use themselves as an instrument of change, focusing on the
quality of the therapeutic relationship.
 Genuine and Authentic: The therapist is genuine, integrated and authentic and can openly express
feelings and attitudes present in the relationship.
 Accessible: Therapists need to be immediately present and accessible to clients, focusing on their
immediate experience.
 Model: Serves as a model of a human being struggling toward greater realness.
 Avoids Confrontation and Interpretation: Client centred therapists encourage careful self
exploration but they tend to avoid confrontation and interpretation as tools for hastening insight.
 "Authentic Chameleon": The therapist adjusts their interpersonal style to match the needs of the
client.
Client's Experience
 Self-Healing: The therapeutic relationship activates the client’s self-healing capacities.
 Openness: As clients feel understood and accepted, their defensiveness lessens, and they become
more open to their experiences.
Intervention Strategies
 Therapist's Attitude: The therapist's attitude, rather than specific techniques, is the key to change.
 Emphasis on the relationship: The approach emphasises the attitudes and personal characteristics
of the therapist and the quality of the therapeutic relationship.
 Present focus: The therapy focuses on the present experience of the client.
Clients who can Benefit
 This therapy has broad application and is useful for fostering good interpersonal skills and respect
for others.
 It is beneficial in the first stage of a crisis.
 Women can benefit from this therapy as they are encouraged to identify their own feelings and
needs.
 People with relationship difficulties can also benefit from this approach.
Limitations
 It may not be suitable for people in crisis situations who need more direct interventions.
 Some clients tend to expect a more structured approach.
In summary, client-centered therapy emphasises the client's inherent capacity for growth and self-
understanding, facilitated by a therapeutic relationship characterised by empathy, unconditional positive
regard, and genuineness. The therapist acts as a facilitator, supporting the client in their journey toward self-
discovery and personal development.
 SECTION – B

Answer the following questions in 400 words each. 5 x 5 = 25 marks

4. Explain the structural and topographical models of personality by Freud.
Sigmund Freud developed complex theories about personality, including the structural and topographical
models. These models aim to explain how the human psyche is organised and how it functions.
Structural Model
 This model, also known as the tripartite model, proposes three components of personality: the id, the
ego, and the superego.
 The Id:
o Present from birth, the id operates on the pleasure principle, seeking immediate gratification
of needs and desires, without considering reality.
o It is the source of all basic biological urges such as hunger, thirst and sex.
o The id is unconscious and impulsive.
o For example, a hungry baby cries, demanding food without regard for their parent's situation.
 The Ego:
o The ego develops within the first three years of life as a child interacts more with the world.
o It operates on the reality principle, understanding that others have needs and that impulsive
actions can have negative consequences.
o The ego's job is to meet the needs of the id, while taking reality into account. It engages in
planning and decision-making, referred to as secondary process thinking.
o The ego directs energy from the id.
 The Superego:
o The superego develops by the age of five, or the end of the phallic stage, and is the moral
component of personality.
o It operates as a person's conscience, dictating beliefs about right and wrong, and develops in
response to moral and ethical restraints placed on the individual by caregivers.
o The superego includes a person's goals and ideas about how one wants to behave (the ego-
ideal).
o While the id and ego are considered characteristics of the individual, the superego is based on
outside influences like family and society.
o For example, children learn from their family what actions and behaviours are acceptable and
learn to act in ways that win praise and affection.
 In a healthy person, the ego is the strongest force, capable of balancing the demands of the id and
superego while remaining in touch with reality. If the id becomes too dominant, a person will be
ruled by their impulses and self-gratification. If the superego is too strong, the person will be rigid,
judgmental, and unbending.
Topographical Model
 Freud also proposed a topographical model of the mind, which divides mental processes into three
levels of awareness: conscious, preconscious, and unconscious.
 Conscious:
o The conscious level contains everything that we are aware of at any given moment.
o Freud believed that this is a very small part of who we are.
 Preconscious/Subconscious:
o The preconscious holds information that is not in our active awareness but can be easily
retrieved if prompted.
o This includes stored information, such as telephone numbers, childhood memories, or the
name of a childhood friend.
 o It is right below the surface of the conscious, but still somewhat buried unless actively
searched for.
 Unconscious:
o The unconscious contains the majority of feelings, beliefs, and impulses that are not available
to us at a conscious level.
o This includes repressed feelings and thoughts, such as those associated with the Oedipus or
Electra complex, that were pushed out of awareness due to anxiety.
o Freud posited that buried unconscious material continues to dramatically impact behaviour.
 Freud likened this model to an iceberg. The small visible tip of the iceberg represents the conscious,
while the vast, submerged part represents the unconscious. The water itself represents the
nonconscious: everything that an individual is not aware of, has not experienced, and has not
integrated into their personality.

5. Describe the techniques of interpersonal psychotherapy.

Interpersonal psychotherapy (IPT) is a short-term therapy that focuses on the connection between a person's
mood and their interpersonal relationships. It assumes that interpersonal events can lead to depressive
symptoms and that depression can impair a person's interpersonal functioning. IPT aims to improve a
person’s mood by improving their interpersonal functioning. IPT is often used in the treatment of
depression.
Here are some of the key techniques used in IPT:
 Directive and non-directive exploration:
o At the start of sessions, non-directive techniques are used to gather information.
o Therapists ask open-ended questions, and use verbal and non-verbal cues to encourage the
person to talk. They may repeat what the person has said or refer to something said earlier.
o Later in the session, more directive techniques may be used.
o The therapist might ask closed questions to clarify the details of an interpersonal dispute.
 Focus on one of four problem areas: The focus of treatment is on interpersonal problems in one of
four areas: grief, role disputes, role transitions, and interpersonal deficits.
o Grief: The therapist may help the client to facilitate mourning.
o Role disputes: The therapist may help the client to identify issues in disputes and alternative
actions.
o Role transitions: The therapist may encourage the patient to view role transitions in a
positive way.
o Interpersonal deficits: The therapist may work on remediating interpersonal deficits.
 Behaviour change techniques:
o Structured problem-solving is used to help the person find workable solutions to their
problems.
o The therapist may give the person advice when appropriate.
o Role-playing may be used where a patient is asked to speak to the therapist as they would to
another person to clarify their feelings, demonstrate the effectiveness of their
communications, and provide an opportunity to rehearse new ways of communicating.
o Education is an important part of IPT, which includes explaining the symptoms and
treatment of depression, the relationship of events in the person's interpersonal life to their
symptoms, and the process of IPT.
 Focus on the present: While information about past relationships is sought, it is only used to shed
light on current interpersonal functioning. The focus of therapy is on present difficulties.
 Transference and Countertransference:
o In all forms of psychotherapy, it is important to monitor the transference and
countertransference.
 o Therapists should resist the temptation to advise dependent people on how to solve their
problems, and use counselling and structured problem solving to help the clients deal with
their problems.
o The differences between a therapeutic relationship and a friendship should be discussed.
o Therapists should monitor their own feelings about patients and acknowledge unacceptable
impulses to avoid acting on them.
IPT is time-limited, usually involving up to 20 weekly sessions, each lasting one hour. The therapy
maintains a focus on one or two key issues closely related to depression. A shorter version of IPT, called
Interpersonal Counselling (IPC), comprises six half-hour sessions and has been shown to be effective. IPT
does not specifically seek out maladaptive patterns of thinking, nor does it set specific homework tasks.

6. Explain parent child interaction therapy (PCIT).

Parent-Child Interaction Therapy (PCIT) is a unique approach that combines elements of behavioural
therapy, play therapy, and parent training to improve the parent-child relationship. It is designed for children
aged 2 ½ to 8 and their caregivers, and is particularly effective for families where parent-child relations
have broken down or communication is problematic.
Key aspects of PCIT:
 Live Coaching: A distinguishing feature of PCIT is that therapists coach parents in real time as they
interact with their children. This is typically done by the therapist observing the interaction behind a
one-way mirror and using an audio device to provide guidance to the parent. This allows the
therapist to offer immediate feedback and support to the parent as they implement strategies to
reinforce their child’s positive behaviour.
 Two Stages: PCIT is divided into two distinct stages:
o Relationship Development (Child-Directed Interaction): The goal of this stage is to
establish a loving and nurturing bond between the parent and child using a play therapy
approach.
 Parents are taught a list of "Dos" and "Don'ts" to use while playing with their child
during a specific daily play period called Special Play Time.
 Parents are encouraged to follow their child's lead, and to communicate warmth,
positive attention, and enthusiasm.
 Parents are taught an acronym of skills to use during Special Play Time with their
children which is generally either "DRIP" or "PRIDE".
 DRIP stands for Describe, Reflect, Imitate, and Praise.
 PRIDE stands for Praise, Reflect, Imitate, Describe, and Enthusiasm.
o Discipline Training (Parent-Directed Interaction): This stage focuses on establishing a
structured and consistent approach to discipline.
 Parents are taught effective strategies for giving clear instructions, setting limits, and
using consistent consequences for both compliance and noncompliance.
Goals of PCIT:
 Improve Parent-Child Relationship: PCIT aims to create a more loving and nurturing bond
between the parent and child.
 Teach Effective Discipline Techniques: PCIT provides parents with effective strategies for
managing their child's behavior, reducing reliance on negative interactions.
 Reduce Behavior Problems: PCIT aims to decrease problem behaviours in young children by
addressing negative parent-child patterns and teaching parents how to model and reinforce
constructive ways to manage emotions.
 Prevent Child Abuse: PCIT aims to break the cycle of negative behaviors that can contribute to
child abuse by promoting positive interactions and nonviolent discipline techniques.
 Improve Communication: PCIT aims to improve communication patterns between parent and
child.
PCIT is an evidence-based therapy that has been shown to be effective with children who have disruptive
behaviours and with children and families at risk for abuse or neglect. Parent satisfaction with PCIT is
generally high. The model can be adapted for use with various populations and cultures.

7. Describe the different ways to integrate various counseling theories or psychotherapies.

There are several different ways that clinicians and theorists have attempted to integrate various counselling
theories or psychotherapies. These include:
 Eclecticism: This approach involves drawing upon multiple theories to gain insight into phenomena,
without rigidly adhering to any single paradigm or set of assumptions. Eclectic therapists select
techniques based on their perceived efficacy, or because they seem to work. Eclecticism has been
criticised for a lack of consistency in its thinking and a lack of theoretical basis for using specific
techniques.
 Theoretical Integration: This approach involves bringing together theoretical concepts from
different approaches, some of which may present contrasting worldviews. The goal of theoretical
integration is to synthesise different models of personality functioning, psychopathology, and
psychological change. It is considered the most difficult and sophisticated type of psychotherapy
integration.
 Assimilative Integration: In this approach, therapists ground themselves in one system of
psychotherapy, but selectively incorporate practices and views from other systems. Assimilative
integrationists maintain a single coherent theoretical system as a core, while borrowing techniques
from multiple systems. This approach integrates at the practice level, rather than the theoretical
level.
 Common Factors Approach: This approach seeks to identify the core ingredients that different
therapies share in common. It is based on the belief that commonalities are more important in
determining therapy outcome than the unique factors that differentiate among them. The therapeutic
alliance is considered a common factor important across different counselling theory schools.
 Multitheoretical Approaches: These approaches do not attempt to synthesise theories at a
theoretical level, but rather provide a framework for using two or more theories. This approach aims
to bring some order to the diversity in the field of psychotherapy while preserving the valuable
insights of major systems of psychotherapy. Two examples of multitheoretical approaches are the
transtheoretical model and Brooks-Harris’ multitheoretical therapy.
o The Transtheoretical Model: This is a model of behavioural change that integrates key
constructs from other counselling theories. It proposes that change takes place through five
stages: precontemplation, contemplation, preparation, action, and maintenance. It assumes
that different individuals are in different stages of readiness for change and that interventions
must be tailored accordingly.
o Brooks-Harris’ Multitheoretical Model: This model integrates cognitive, behavioural,
experiential, bio psychosocial, psychodynamic, systemic and multicultural approaches. It
starts with the premise that thoughts, actions and feelings interact and are influenced by
biological, interpersonal, systemic, and cultural contexts. This model emphasises when a
therapist might use elements of different theories and offers specific strategies for each area.
 Helping Skills Approach to Integration: This approach, developed by Clara Hill, uses different
therapy schools in three stages of the helping process. The first stage, exploration, uses client-
centered skills like attending, listening and reflection of feelings. The second stage, insight, uses
psychoanalytic skills like interpreting and dealing with transference. The third stage, action, uses
cognitive-behavioural techniques.
Integrative therapy is different from eclectic therapy because it is a considered, methodical attempt to bring
theories and practices together, unlike eclecticism, which focuses more on 'what works' without necessarily
considering why. Integrative therapists are also concerned with why a particular technique works.

8. Explain group psychotherapy in terms of its settings and theoretical principles.

Group psychotherapy is a form of psychotherapy where one or more therapists treat a small group of clients
together. The group context and process are used as mechanisms for change by developing, exploring, and
examining interpersonal relationships within the group.
Settings for Group Psychotherapy
Group therapy can take place in a variety of settings:
 Psychiatric in-patient units: Group therapy is often part of the therapeutic environment in
psychiatric in-patient units.
 Institutional settings: In addition to classical "talking" therapy, group therapy in an institutional
setting can also include group-based expressive therapies such as drama therapy, psychodrama, art
therapy, and non-verbal types of therapy such as music therapy.
 Therapeutic communities: Group psychotherapy is a key component of Milieu Therapy in a
Therapeutic Community. The entire environment is considered a medium of therapy, and all
interactions and activities are subject to exploration and interpretation in daily or weekly community
meetings.
 Outpatient settings: Group therapy can occur in outpatient settings, with approximately 6-10
individuals meeting face-to-face with a trained group therapist. Members decide what to talk about
during group meetings.
Theoretical Principles of Group Psychotherapy
Yalom's therapeutic factors, also known as curative factors, are derived from research with group therapy
users, and are considered therapeutic principles. These include:
 Universality: Recognition that group members share similar experiences and feelings, which can
decrease a member’s sense of isolation and raise self-esteem.
 Altruism: Members can help each other, which can improve self-esteem and promote the
development of adaptive coping and interpersonal skills.
 Instillation of hope: Seeing other members progress can inspire and encourage those who are
struggling.
 Imparting information: Members can learn helpful factual information from each other, such as
about treatments or access to services.
 Corrective recapitulation of the primary family experience: Members may unconsciously
identify the therapist or other group members with their parents and siblings in a form of
transference. Therapists can interpret these patterns to help members understand the impact of
childhood experiences on their personality, and to avoid repeating unhelpful past patterns in present
day relationships.
 Development of socialising techniques: The group setting provides a safe environment to practice
new ways of interacting and to learn from observing and imitating the therapist and other members.
 Cohesiveness: This is the primary therapeutic factor. A cohesive group is one where all members
feel a sense of belonging, acceptance, and validation.
 Interpersonal learning: The process of learning from the interpersonal interactions and feedback of
others in the group.
 Self-understanding: Achieving greater insight into the origins of one's problems and the
unconscious motivations behind one's behaviour.
Other Important Principles
 Group interaction: Interaction between members is highly encouraged and provides opportunities
to try out new behaviours and learn more about the way they interact with others.
 Safe environment: Groups should provide a safe environment in which members can establish trust
and talk personally and honestly.
 Confidentiality: Group members must commit to maintaining the confidentiality of the content of
group sessions.
 Therapist facilitation: The therapist facilitates the group process and guides individuals in self-
discovery. The therapist may provide direction when the group gets off track but otherwise lets
members set their own agenda.
  Emphasis on commonalities: The therapist will emphasize the commonalities among members to
instill a sense of group identity.
 Homogeneous or heterogeneous groups: Groups may be homogeneous (members with similar
diagnostic backgrounds) or heterogeneous (members with a mix of different emotional problems).
 Open or closed membership: Membership may be closed (no new members) or open (new
members may join).
The goal of group therapy is to help with solving emotional difficulties and to encourage the personal
development of the participants in the group. Group therapy allows people to recreate the difficulties that
brought them to therapy. The group is able to provide support, offer alternatives, and comfort members, so
that difficulties can be resolved and alternative behaviours can be learned.

SECTION – C

Answer the following questions in 50 words each. 10 x 3 = 30 marks

9. Ego defense mechanisms

Ego defence mechanisms are unconscious psychological strategies used by the ego to protect itself from
anxiety arising from conflicts between the id, superego and reality. According to Freudian theory, the ego
mediates between the instinctual demands of the id, the moralistic constraints of the superego, and the
demands of the external world. When the ego struggles to balance these competing forces, it employs
defence mechanisms to reduce feelings of tension and anxiety. These mechanisms operate outside of
conscious awareness and can be both helpful and harmful depending on the context and frequency of use.
The sources describe the following ego defence mechanisms:
 Denial: Arguing against an anxiety-provoking stimulus by stating it does not exist. For example,
denying a physician's cancer diagnosis and seeking a second opinion.
 Displacement: Taking out impulses on a less threatening target. For example, slamming a door
instead of hitting a person, or yelling at a spouse after an argument with a boss.
 Intellectualisation: Avoiding unacceptable emotions by focusing on the intellectual aspects of a
situation. For example, focusing on the details of a funeral rather than the sadness and grief.
 Projection: Placing unacceptable impulses or feelings onto someone else. For example, when losing
an argument, stating, "You're just stupid," or expressing homophobia.
 Rationalisation: Supplying a logical or rational reason as opposed to the real reason for a thought or
action. For example, stating that one was fired because they did not "kiss up" to the boss, when the
real reason was poor performance.
 Reaction Formation: Taking the opposite belief because the true belief causes anxiety. For
example, having a bias against a particular race or culture and then embracing that race or culture to
the extreme.
 Regression: Returning to a previous stage of development. For example, sitting in a corner and
crying after hearing bad news, or throwing a temper tantrum when you do not get your way.
 Repression: Pulling thoughts, feelings, or memories into the unconscious. For example, forgetting
sexual abuse from childhood due to the trauma and anxiety. Repressed ideas and memories are
considered implicit declarative knowledge.
 Sublimation: Acting out unacceptable impulses in a socially acceptable way. For example,
sublimating aggressive impulses toward a career as a boxer or becoming a surgeon because of a
desire to cut.
 Suppression: Consciously pushing thoughts or feelings into the unconscious. For example, trying to
forget something that causes anxiety. This differs from repression in that it is a conscious act.
Suppression is considered explicit procedural memory because it involves the conscious banishment
of certain thoughts and/or feelings from one’s mind.
The Role of Ego Defences Ego defences are not inherently unhealthy. They play an important role in
normal development. The ego uses them to manage conflicting demands of the id and superego in order to
maintain a sense of internal equilibrium. However, overuse or inappropriate use of defence mechanisms can
be destructive. The inability to use these defences effectively can lead to problems in life. Defence
mechanisms are primarily in the domain of implicit procedural memory.
Ego Defences in Therapy In psychodynamic therapy, the analysis of defences is a central focus. By
examining a patient's defence mechanisms, the therapist can gain insight into the patient's unconscious
conflicts. The therapist helps the patient become aware of these defences and understand their function,
allowing the patient to respond to their motivations more honestly and in a healthy manner.
Limitations of Freudian Theory
It is important to note that Freudian theory, including the concept of ego defence mechanisms, has
limitations:
 Freud's hypotheses are difficult to verify or disprove.
 The theory is based on an inadequate conceptualisation of the experience of women.
 The theory may overemphasize the role of sexuality in human psychological development.

10. Narrative therapy

Narrative therapy is a form of psychotherapy that emphasizes the stories people create to make sense of
their experiences. It views these personal accounts or narratives as a way to establish identity as social and
political constructs based on local knowledge. Therapy is seen as a form of conversation that encourages
reflection and can transform problem-saturated narratives into more positive accounts.
Key Concepts and Techniques of Narrative Therapy:
 Externalisation: This technique separates the person from the problem, which can help the
individual feel less blamed and more able to join with their family in fighting the problem.
 Emphasis on language: Narrative therapy focuses on the way people use language to construct their
experiences.
 Co-editors of reality: Therapists see themselves as co-editors of their clients' realities, avoiding
marginalisation and recognizing that "the person is not the problem, but the problem is the problem".
 Unique outcomes and positive exceptions: Narrative therapists look for unique outcomes and
positive exceptions to the problem, similar to the approach taken in solution-focused therapy.
 Reflection: Therapy involves conversations that encourage reflection.
 Stories and Storytelling: Narrative therapy can incorporate stories and storytelling ideas, which can
be helpful when working with children.
How Narrative Therapy Works:
Narrative therapy helps people re-author their stories by:
 Identifying problem-saturated narratives: Recognizing and exploring the negative stories that
dominate a person's understanding of themselves and their situation.
 Deconstructing dominant narratives: Examining the cultural and social influences that contribute
to the development of problem-saturated stories.
 Finding unique outcomes: Identifying exceptions to the problem story, or times when the problem
did not occur or was less severe.
 Re-authoring stories: Creating new, more positive and empowering narratives that emphasize
strengths, resources, and possibilities.
Narrative Therapy in Different Contexts:
 Children and Families: Narrative therapy can be effective when working with children and families
by using techniques like externalisation to help children feel less blamed for family difficulties. It
can help children feel engaged and less blamed, as well as connecting with them through the use of
storytelling ideas.
 Individuals: Narrative therapy can be used with individuals to explore how they make sense of their
experiences and how they establish their identity.
Comparison with other therapies:
 Solution Focused Therapy: Both narrative therapy and solution-focused therapy share an interest in
identifying exceptions to problems. However, solution focused therapy focuses more directly on
finding solutions rather than exploring narratives.
 Cognitive Behavioral Therapy (CBT): Unlike CBT which focuses on changing maladaptive
thinking patterns, narrative therapy focuses on changing the stories people tell about themselves.
 Psychodynamic therapy: Narrative therapy differs from psychodynamic approaches, which
emphasize unconscious motivations and past experiences, by focusing on conscious narratives and
current interpretations.
Limitations of Narrative Therapy:
 Emphasis on language: The focus on language may not be appealing or accessible to all clients,
particularly children.
 Past experiences: Unlike some therapies that emphasize the importance of exploring past
experiences, narrative therapy has less focus on the past, and more on the present stories.
In summary, narrative therapy is a unique approach that helps people to change their lives by changing the
stories they tell about themselves and their experiences.

11. Psychosexual stages of development

Sigmund Freud's theory of psychosexual development proposes that personality develops through a series of
predetermined stages, each associated with a particular erogenous zone. According to Freud, these stages
are completed in a sequence, and successful or unsuccessful completion of each stage can affect adult
personality. If a child does not successfully navigate the challenges of a particular stage, they may become
fixated on that stage, leading to specific personality traits and behaviours in adulthood.
The psychosexual stages of development according to Freud are:
 Oral Stage (Birth to 18 months):
o The focus of pleasure during this stage is on the mouth and oral activities like sucking.
o Fixation in this stage, due to either over or under-gratification, can lead to an "oral
personality," characterised by a preoccupation with oral activities like smoking, drinking,
overeating, or nail-biting.
o Such individuals may also demonstrate over-dependence on others, gullibility, and a
tendency to be followers or, on the opposite end of the spectrum, pessimism and aggression.
 Anal Stage (18 months to three years):
o The focus of pleasure shifts to the anus, and the child gains pleasure from controlling bowel
movements.
o Fixation at this stage, often due to conflicts around toilet training, can result in either an
"anal retentive" personality, marked by an obsession with cleanliness, perfection, and control,
or an "anal expulsive" personality, characterised by messiness and disorganisation.
 Phallic Stage (ages three to six):
o The focus of pleasure now shifts to the genitals.
o Freud proposed that boys develop unconscious sexual desires for their mother during this
stage, which he called the Oedipus complex. They also view their father as a rival for the
mother's affection, causing a fear of castration by the father.
o Though Freud disagreed with the concept, some psychoanalysts have described the
comparable experience in girls as the Electra complex, which includes unconscious sexual
attraction to their father.
o A fixation during the phallic stage may result in sexual deviancies, weak or confused sexual
identity.
 Latency Stage (age six to puberty):
o During this stage, sexual urges are repressed, and children mainly engage in play and
interaction with same-sex peers.
 o This stage is a period of relative calm in terms of psychosexual development.
 Genital Stage (puberty on):
o The final stage begins with puberty, during which sexual urges reawaken. Adolescents now
direct their sexual urges toward opposite-sex peers with a focus on the genitals.
o Successful completion of previous stages is thought to enable adolescents to form healthy
sexual relationships and engage in mature behaviour.
Important Considerations:
 Erogenous Zones: Each stage is associated with a specific erogenous zone, and conflicts or
fixations related to that zone are believed to shape personality development.
 Gratification: Freud posited that successfully passing through each stage depends on an adequate
amount of gratification—not too much or too little.
 Controversy: Freud’s theory of psychosexual development is both well-known and controversial,
particularly his emphasis on sexuality and the Oedipus and Electra complexes.
 Limitations: The theory is criticised for overemphasising the role of sexuality and for being difficult
to verify empirically.
While these stages are central to Freudian theory, it is noted that the concepts may not be as crucial to
psychoanalytic and psychodynamic models as other tenets.

12. Cognitive analytic therapy

Cognitive analytic therapy (CAT) is a brief, structured, and collaborative therapy that integrates elements
of both analytic (object relations theory) and cognitive psychotherapy traditions. CAT is considered a
relational therapy because it emphasizes the interpersonal aspects of mental health difficulties. It aims to
provide a therapeutic journey from past trauma to a reconnection with dialogue and meaning.
Key Features and Concepts of CAT:
 Integration of Theories: CAT integrates concepts from:
o Personal construct theory: This theory emphasizes how individuals create their own
understanding of the world.
o Cognitive and developmental psychology: These fields focus on mental processes and
development throughout life.
o Psychoanalytic object relations theory: This theory emphasizes the importance of early
relationships in shaping how individuals relate to themselves and others.
o Vygotsky's activity theory: This theory highlights the dialogic nature of human experience,
in which internalised self-other relationships become the basis of reciprocal role procedures
that govern intrapersonal and interpersonal relationships.
 Emphasis on Shared Meaning: CAT places a strong emphasis on the client's life story and the
shared meaning within the therapeutic relationship.
 Repetitive Patterns: CAT theory emphasizes the repetitive sequences of cognition, emotion,
behaviour, and their consequences (called "procedures"), which are similar to the Situation, Thought,
Affect, Intention, Response, Consequence, and Self Evaluation (STAIRCASE) model in cognitive
behavioural therapy (CBT).
 Therapeutic Relationship: CAT recognizes the therapy relationship as a place where interpersonal
patterns are enacted. The therapist and patient collaboratively explore the reciprocal roles being
played out in their relationship, particularly when the therapeutic alliance is threatened.
 Collaborative Approach: The therapist and patient work together to understand the patient’s story
and how their past and present experiences are linked.
 Reformulation: In the initial sessions of CAT, an extended assessment is conducted to develop a
jointly agreed reformulation of the patient's story. This includes:
o Identifying problematic and repetitive patterns (procedures).
o Diagrammatic representation of the reformulation, which act as a psychological tool, to
facilitate focused attention and self-reflection.
o A narrative account that is redrafted based on the patient’s feedback.
  Focus on Dialogue: CAT emphasizes the importance of "dialogue," both cathartic and reparative,
within the therapeutic relationship.
 Time-Limited: CAT is designed to be a brief therapy.
How CAT Differs from CBT
While CAT shares some similarities with CBT, it also has some differences:
 Focus:
o CBT focuses on changing maladaptive thoughts and behaviours directly.
o CAT emphasizes the relationship between past and present experiences, using a dialogic
approach to integrate those aspects into understanding current patterns.
 Techniques:
o CBT uses techniques like cognitive restructuring and behavioural activation.
o CAT utilizes the jointly agreed upon reformulation of a patient's story as a starting point for
intervention and uses cognitive-behavioural methods for procedural revision.
 Approach:
o CBT tends to be more directive, with the therapist acting as a coach to facilitate new
experiences.
o CAT is collaborative, with both therapist and client working together on interpretations, and
uses the therapeutic relationship as a way to help understand relationship patterns.
Applications of CAT
 CAT can be helpful for understanding how past trauma and low self-esteem can contribute to
anxiety, depression, and self-destructive behaviours.
 It is also useful for people with personality disorders, such as borderline or narcissistic traits.
 CAT is suitable for older adults, with whom it can help explore feelings of guilt and helplessness
following life changes.
 CAT is useful in understanding the role-play between the caregiver and person with dementia.
 CAT has been used as a very brief intervention in situations such as repeated deliberate self-harm.
Limitations of CAT
 The evidence base for CAT is still developing.
In summary, CAT is a flexible, integrative therapy that combines cognitive and analytic concepts to help
people understand their relationship patterns and create more positive and fulfilling lives. It uses a
collaborative and relational approach, with emphasis on dialogic exploration to link past experiences to
current issues.

13. Inferential distortions

Inferential distortions are inaccurate or illogical ways of thinking about events and circumstances, often
leading to negative emotions and behaviours. These distortions are considered irrational because they
misinterpret reality, are not supported by evidence, and block people from achieving their goals. These
distortions are based on "guesses" about what is happening.
The sources describe seven types of inferential distortions:
 Black and white thinking: Also called all-or-nothing thinking, this involves seeing things in
extremes with no middle ground, such as good or bad, perfect or useless. For example, viewing a
situation as either a complete success or a total failure.
 Filtering: This is when a person focuses only on the negative aspects of a situation, while ignoring
any positive elements. This can be focusing on what is wrong with oneself, or what is wrong with
the world, while ignoring the positives.
 Over-generalisation: This involves taking one instance and applying it to all situations, thinking
that it represents the whole. For instance, believing that because something has happened once or
twice, it will happen all the time. Examples include statements such as 'everything's going wrong' or
'I'll always be a failure'.
  Mind-reading: Making assumptions about what other people are thinking without any evidence.
This could be guessing that someone is angry or ignoring you on purpose.
 Fortune-telling: Treating beliefs about the future as if they are facts, rather than predictions.
Examples include thinking that you'll be depressed forever, or that things can only get worse.
 Emotional reasoning: This involves thinking that because you feel a certain way, this is how it
really is. For example, feeling like a failure, and thus believing that you must be a failure.
 Personalising: Assuming responsibility for things that happen without any proof. For example,
believing that you caused a team to fail, or that you must have made someone feel bad.
These distortions are part of the way people infer what is going on in their lives and form evaluations based
on these inferences. It is important to note that these inferences and evaluations can be made both
consciously and subconsciously.
Core beliefs, which are general assumptions and rules that guide how people react to events, underlie
inferential distortions and evaluations. Core beliefs are usually subconscious, and these beliefs determine
how an individual will react to life.
These inferential distortions and core beliefs are key concepts in therapies like cognitive behavioural
therapy (CBT) and rational emotive behaviour therapy (REBT). REBT practitioners use strategies that
examine the logic behind beliefs. CBT aims to modify cognition to create productive change in
dysfunctional emotions and behaviours.

14. Difference between positive punishment and negative punishment

Positive punishment and negative punishment are both methods used in operant conditioning to decrease
the likelihood of a behaviour occurring again, but they achieve this in different ways.
 Positive punishment involves the addition of an aversive stimulus following a behaviour, which
makes the behaviour less likely to occur in the future.
o For example, if a child misbehaves and a parent scolds them, the scolding (an aversive
stimulus) is added to the situation in order to reduce the misbehaviour. Other examples of
positive punishment are disapproval, criticism, pain, and fines.
o Positive punishment is what most people mean when they use the word "punishment".
 Negative punishment involves the removal of a desirable stimulus following a behaviour, which
makes the behaviour less likely to occur in the future.
o For example, if a child misbehaves and a parent takes away their screen time, the loss of
screen time (a desirable stimulus) reduces the probability of the misbehaviour. Other
examples of negative punishment include the loss of tokens in a token system and time-out.
o Negative punishment is sometimes called "response cost".
Here's a table summarizing the key differences:
Feature Positive Punishment Negative Punishment
Action Adding an aversive stimulus Removing a desirable stimulus
Effect on Decreases the probability of the behaviour Decreases the probability of the behaviour
behaviour occurring occurring
Examples Scolding, criticism, extra work, fines Loss of privileges, time-out, response cost
It is important to note some considerations for using punishment.
 Punishment may condition reactions such as fear, anxiety, or hate to the people who administer the
punishment or the situations in which it occurs.
 The person being punished may learn to escape or avoid these people or situations.
 Punishing agents may act as models for aggressive behaviour.
 Punishment needs to be applied immediately and consistently after the behaviour to be effective.
 Punishment should be used with caution, and should generally be coupled with extinction and
reinforcement of alternative behaviours.
Both positive and negative punishment are often less effective than reinforcement, and there may be
negative side effects, so it is important to take care when using them as behaviour change strategies.
 15. Token economies
Token economies are a type of contingency contracting program that uses tokens as a form of
reinforcement. These tokens, such as poker chips, stars, marks on a chart, or punch holes in a card, are given
to a person after they perform a desired behaviour. The tokens can then be exchanged later for a choice of
reinforcers from a reinforcement menu. Token economies are used in a variety of settings.
Key features and aspects of token economies include:
 Reinforcement: Tokens act as a type of positive reinforcement. They increase the likelihood that a
desired behaviour will be repeated because they can be exchanged for something of value.
 Contingency: The tokens are contingent on the desired behaviour. This means that the tokens are
given only when the specific behaviours are performed.
 Reinforcement Menu: The reinforcement menu offers a variety of items and privileges to be
purchased with tokens. This variety is important to ensure that the tokens remain reinforcing because
it reduces the likelihood of a person satiating on any one particular reinforcer.
 Immediacy of Reinforcement: Tokens can be dispensed immediately after the desired behaviour.
This immediacy is important for effective reinforcement.
 Delay of Reinforcement: Token economies also address the issue of delayed reinforcement, as
tokens can be earned immediately and then saved for larger rewards later.
 Flexibility: Token systems can be used in a variety of settings, such as hospitals, classrooms, and
homes. The tokens and reinforcers can be adapted to the specific setting and the individuals
involved.
Examples of how token economies work:
 In a classroom, a teacher may give students checks on a clipboard for appropriate behaviour or
completing tasks. These checks can then be exchanged for longer recess, being a teacher's aide, field
trips, dances, or time in a special reward area.
 In a home situation, a child may earn tokens each day for completing chores. They can use some of
the tokens for smaller daily rewards, like staying up an extra half-hour, and save others over a period
of time for a larger reward like a new toy.
 In a hospital setting, patients may earn tokens for engaging in desired behaviours such as daily
living skills, social interactions, or work tasks. These tokens can then be exchanged for privileges,
like extra free time or special items.
Benefits of token economies include:
 They address the issue of delay of reinforcement, because tokens can be given immediately even if
the reinforcer is not immediate.
 They reduce the problem of satiation on any particular reinforcer because the person can choose
from a variety of reinforcers.
 They provide a clear and structured way to implement positive reinforcement.
Token economies are a powerful tool in behaviour modification because they provide a flexible and
effective way to reinforce desired behaviours.
It is important to note that the strength of token systems is that they deal with the issue of delay of
reinforcement. The tokens are often easily dispensed and can be given fairly immediately after the desired
behaviour.

16. Five stages of dying by Kubler-Ross

Kubler-Ross proposed a theory that many dying people progress through five stages of dying. It's important
to note that some researchers have questioned whether these stages apply to all dying people. The five
stages are:
 Denial: Initially, the reaction is disbelief, with the person responding with "No! Not me!". Though
denial is rarely complete, most people initially respond with disbelief in the seriousness of their
illness.
  Anger: In this stage, the dying person expresses anger, resentment, and hostility at the "injustice" of
dying, often projecting these attitudes onto others.
 Bargaining: The dying person tries to "make deals" to prolong life, for example, making promises
to a higher power.
 Depression: Here, the person may be overwhelmed with feelings of loss, hopelessness, shame and
guilt, and may experience "preparatory grief".
 Acceptance: In the final stage, one comes to terms with death, not necessarily happily, but with a
feeling of readiness to meet it.
These stages represent common emotional reactions that dying individuals may experience. It should be
noted that not everyone will experience these stages, and that the therapeutic implications of this model are
not necessarily appropriate for everyone.
It is also important to understand that these stages are not necessarily linear. People may move back and
forth between stages, or not experience some stages at all.
Kubler-Ross's work was important in bringing attention to the emotional needs of dying patients. Her model
suggests that the emotional conflicts and defence mechanisms of a dying person should be addressed, with
the goal of resolving the psychic crisis as fully as possible.

17. Empathy
Empathy, in the context of therapy, is the ability of a therapist to understand a client at a deep level, from
the client's perspective. It involves the therapist attempting to "live" in the client's internal frame of
reference. This means that the therapist tries to understand the client's unique experiences, feelings, and
perceptions of their problems.
Key aspects of empathy, according to the sources:
 Internal Frame of Reference: Empathy requires the counsellor to understand the client's unique
experience of their personal problems. This involves carefully listening to what the client is
conveying, both verbally and nonverbally, at every stage of the counselling process.
 Active Listening: To stay within the client's internal frame of reference, the counsellor needs to
listen carefully to the client. Active listening includes paying attention to both the content and the
feelings the client expresses. It also involves using both verbal and nonverbal cues to show
attentiveness.
 Communication: Once the counsellor understands the client's feelings and experiences, this
understanding must be communicated back to the client. This involves reflecting the content and
feelings of the client back to them to check for accuracy of understanding. For example, a counsellor
might say "I hear you saying..." or "So you are feeling... because of...".
 Non-Judgmental: Empathy requires the therapist to avoid imposing their own views, values, or
interpretations onto the client. Instead, the therapist is trying to understand the client's perspective,
not to judge it.
 More Than Reflection: Empathy is more than simply restating what the client has said or reflecting
feelings. It also involves a more profound understanding of the client's world and their experiences,
and conveying those insights to the client.
 Advanced Empathy: There are different levels of empathy. While primary empathy involves
attending, listening, and communicating back an understanding of the client's position, advanced
empathy incorporates self-disclosure, directiveness, and interpretations. This sophisticated version of
empathy includes more active counsellor processing and the implicit use of a theoretical framework.
Usefulness of Empathy in Therapy:
 Therapeutic Change: Some therapies believe that empathy, along with unconditional positive
regard, and congruence (genuineness), are necessary and sufficient conditions for therapeutic
change.
 Self-Awareness: As the relationship between client and therapist develops, empathy facilitates the
client's re-experiencing of feelings, leading to self-awareness and a recognition of connections
between past and present experiences.
  Trust and Safety: Empathy helps create a safe, caring environment where clients can get in closer
touch with positive aspects of themselves that may have been hidden or distorted. This, in turn,
allows clients to trust that they can rely on their own organism for effective responses.
 Reduced Defensiveness: When clients feel understood and accepted, their defensiveness is reduced
and they become more open to their experiences.
 Challenging Activity: Empathy can be a confronting activity, challenging clients about the quality
and validity of their feelings.
 Corrective Experience: By expressing an understanding of the client’s experience, the therapist
offers a corrective emotional experience that allows the client to experience past problems in new
and more benign ways.
 Validation: Empathy validates the patient's point of view, which may mitigate long-standing
feelings of being disbelieved or dismissed.
 Deeper Understanding: Empathy enables a therapist to see behind surface interactions and
recognize feelings that clients may not even be aware they are expressing.
 Therapeutic Relationship: Empathy is a foundational component of the therapeutic relationship,
providing an environment that fosters growth.
Empathy and Projective Identification
Empathy can also be viewed as a form of projective identification, but one that is explicitly or implicitly
ongoing. It involves a willingness to alter one's perceptions based on the other person's communication.
Unlike defensive projective identification, which is characterised by inflexibility and certainty, empathic
projective identification is marked by a willingness to adapt perceptions based on new information.
Empathy vs. External Frame of Reference:
The opposite of empathy is the "external frame of reference", where the counsellor does not understand or
connect with the client's perspective. When a counsellor views the client from an external frame of
reference, there is little chance that the client's view will be heard, which is not helpful in therapy.
In summary, empathy is a core element of effective therapy, involving a deep, non-judgmental
understanding of the client’s experiences and feelings, communicated in a way that fosters a
therapeutic relationship and promotes self-awareness, trust and growth. It is an active process that
requires the therapist to be fully present, to listen carefully, and to engage with the client’s inner world.

18. Psychotherapy in dementia

Psychotherapy for individuals with dementia is an important area that needs further investigation. A
significant portion of the older population experiences cognitive limitations due to progressive dementia,
often accompanied by emotional distress. While traditional psychotherapy is not usually considered suitable
for those with dementia due to cognitive deficits, these symptoms should not be viewed solely as biological
but as influenced by social, psychological, and environmental factors. Thus, people with dementia can still
benefit from psychological interventions.
Goals of Psychotherapy in Dementia Psychological interventions aim to help those with dementia in
several ways:
 Reduce disruptive behaviours and excess disabilities.
 Increase or maintain positive behaviours.
 Improve memory or learn coping skills to manage loss of cognitive skills.
 Improve quality of life.
 Reduce burden on health-care systems.
 Alleviate symptoms of depression or anxiety.
 Help adjustment to multiple losses.
Types of Psychotherapeutic Interventions Several types of interventions are used in dementia care:
 Cognitive Behavioural Therapy (CBT): CBT can help individuals with early-stage dementia
develop coping strategies and reduce distress. It focuses on negative thoughts and their reinforcing
behaviours, challenging unhelpful thinking, reducing negative behaviours, and introducing positive
 behaviour patterns. Adaptations to CBT for older adults may include increased focus maintenance,
acknowledgement of feelings of guilt and helplessness, and awareness of the interaction of
somatisation and physical symptoms of organic disease.
 Behavioural and Environmental Treatments: These can be effective for managing behaviour
problems and optimising remaining abilities.
 Memory and Cognitive Retraining: This may be used for some forms of late-life cognitive
impairment. However, the effectiveness of cognitive training is disputed.
 Support Groups: These can assist those with early-stage dementia in developing coping strategies
and reducing distress.
 Reminiscence Therapy (RT): RT can provide interpersonal connections for individuals with mild
to moderate stage dementia by encouraging them to remember and share past memories. This is
frequently used in senior and residential settings.
 Family and Systemic Approaches: These can be useful in exploring a diagnosis of early dementia.
They address the individual within the context of the wider family, which is particularly helpful in
communicating and processing the diagnosis of dementia in a family setting.
Psychodynamic Insights Insights from psychodynamic theory can help understand the relationship
between the caregiver and the person with dementia, and prevent interactions that reinforce isolation.
General Approach A general approach based on the principles of validation therapy (a method that
acknowledges and respects the feelings of a person with dementia) with time for reminiscence and life
review provides a humane backdrop to dementia care in many settings.
Modifications of Therapy
Psychotherapy for older adults with dementia often requires adaptations. These include:
 A slower pace due to sensory problems and slower learning rates.
 Repetition of information and presentation in verbal and visual forms.
 Encouragement of note-taking to aid memory.
 A collaborative style with few clearly outlined goals, taking a more active, task-focused approach.
 Focusing on the goals of therapy to reinforce its purpose and direction.
 Facilitation of therapy for those with sensory problems, such as pocket talkers for hearing
impairments.
 Leading older adults to conclusions rather than expecting them to infer answers.
 Flexibility in scheduling, location, and collaboration, due to hospitalisations, reduced mobility, or
the need to care for others.
 Involvement of caregivers in the treatment when necessary.
Clinical Considerations Therapists should be aware of both maturational effects (common to older
adulthood) and cohort effects (specific to a certain birth-year group) when working with older adults with
dementia. They should also be knowledgeable about chronic illnesses, pain management, medication
adherence, and the behavioural signs of negative medication effects.
Psychological therapies are important for improving the quality of life and addressing emotional and
behavioural issues that may arise with dementia. The choice of therapy will depend on the availability of
expertise and the specific needs of the individual and their family.