Psychology: an introduction (Oxford Southern Africa) - Leslie Swartz 2011

Psychotherapies
Mental health

Adelene Africa

CHAPTER OBJECTIVES

After studying this chapter you should be able to:

•describe what psychotherapy is

•explain the central ideas of psychoanalytic psychotherapy, cognitive-behavioural therapy, experiential and relationship-oriented therapies, and systems and postmodern therapies

•differentiate between the therapeutic techniques and procedures employed by each approach

•describe how each approach can be applied in a case of psychological distress

•describe the role that indigenous therapies can play in promoting psychological well-being.

CASE STUDY

Melinda, when thinking about psychotherapy, used to imagine a person lying on a couch while a grey-haired man sat on a chair taking notes. This was the way that therapy was often shown in cartoons and movies. Among her friends it was often just something to joke about. ’He needs a bit of therapy’, they might say about some young man who was being irritating.

But Melinda’s ideas about therapy and therapists changed when she first started university. In those first few months, she felt terribly lonely and very afraid of everything. She got to the point where she would wake up in the morning with a stomach ache and a feeling of dread at having to go to her lectures. She went to see one of the doctors at the Student Health Clinic who, instead of just giving her something for her stomach pain as she had expected, told her she was suffering from anxiety and referred her to the one of their psychologists. Although she didn’t really want to go at first, looking back, it was one of the best things that she could have done.

The psychologist she saw was a lovely, gentle woman who was easy to talk to. Melinda found herself telling her everything she was feeling and, in one session, she broke down and cried and cried. Somehow, talking about the problem — and even crying — made her feel better. While the psychologist didn’t really give advice, she did help Melinda feel that her problems were manageable. She seemed to be able to ask questions and say things that not only sounded like she understood what Melinda was feeling, but also helped her see things in a new light. Somehow, after a session, Melinda didn’t feel quite so stuck and she began to feel that she would be able to cope with the new demands of university. Melinda only went for six sessions, but in the end she felt much better than when she started.

Now, thinking back, it was hard for Melinda to pin down exactly what it was about the therapy that had made her feel better. She was curious to find out more about how therapy worked.

Introduction

The term ’psychotherapy’ conjures up pictures of mentally ill people who seek treatment from psychologists and/or psychiatrists. However, as we will see, this stereotype is limiting as it does not allow us to consider the role that psychotherapy can play in helping people who do not suffer from serious psychopathology (Corey, 2013). Corey (2013) defines psychotherapy as an engagement between two individuals, namely the therapist and the client; he sees this as a collaborative relationship and says the engagement is bound to change both parties. This definition does not specify any particular psychotherapeutic techniques and therefore aptly describes the essence of individual models of psychotherapy. It is important to note that there are other models of psychotherapy for groups, as well as psychological interventions that are aimed at communities (see Chapter 26). However, in this chapter we will be focusing specifically on individual psychotherapy.

There are numerous psychotherapeutic approaches, which advocate various ways in which change can be brought about within the client. Prochaska and Norcross (2010) suggest that there has been a ’hyperinflation’ of therapies over the last 50 years and note that there are more than 400 models of psychotherapy that are currently in use. However, we will limit our discussion to a few of the dominant models of individual psychotherapy, which will give us some idea as to the diversity in theory and practice. Prochaska and Norcross (2010) attempted to identify the common factors in psychotherapies and suggest that the client’s positive expectations and the therapeutic relationship are the two most significant aspects for a positive outcome in psychotherapy.

25.1INTRODUCING THE CASE OF THEMBA

Themba is an 18-year-old first-year student who lives in a university residence. He has been experiencing difficulty in sleeping and has not had an appetite for several days. He feels lethargic and does not have any energy to play soccer, which used to be his favourite sport. He describes his mood as being heavy and indicates that there are times when he feels very sad. He has not been coping with his academic work and has not been able to meet his essay deadlines. He has not been attending lectures as he has difficulty concentrating and feels that he is not learning anything. He has experienced similar bouts of depression before and cannot understand why he feels this way, as he does not seem to have any serious problems that may cause him distress. He does not know where all these unpleasant feelings stem from and feels that his current experience is worse than previous ones. He has tried talking about his situation to his best friend, Sipho, but it has not made him feel any better. He is thinking about leaving university as he feels that there is no point in pursuing his studies.

Themba is clearly experiencing psychological distress and has tried to deal with it by talking to a friend. However, this has not helped and he appears to be feeling worse than on previous occasions. What other sources of help or support can Themba seek? Can psychological intervention assist him in dealing with his problems? What is psychotherapy and what are the various approaches that are available? These are some of the questions that we will address in this chapter.

Table 25.1 The key ideas of the four core approaches to psychotherapy (Corey, 2013)

Corey (2013) divides the psychotherapeutic approaches into four categories. These are psychodynamic approaches, cognitive-behavioural approaches, experiential and relationship-oriented approaches, and systems and postmodern approaches (see Table 25.1).

Psychoanalytic psychotherapy

Analytic or psychodynamic approaches, which are the derivatives of traditional psychoanalysis, are largely concerned with helping the client to gain insight into the underlying causes of emotional difficulties in order to bring about changes within personality and behaviour. These approaches are rooted in the psychoanalytic model, which was developed by Sigmund Freud. Psychoanalysis is largely regarded as the foundation for other models of psychotherapy and has had a major influence on the development of these models. Despite the decrease in dominance of psychoanalysis in recent years, several psychodynamic approaches, which are influential within the therapeutic arena, have developed from it (Ursano & Silberman in Weiten, 2001). For this reason it is useful for us to consider the central ideas within this therapeutic approach.

Figure 25.1 ’The way this works is that you say the first thing that comes to your mind’

Psychoanalysis is concerned with uncovering the factors that motivate behaviour, and Freud believed that the roots of psychological distress lie within the unconscious. The resolution of distress depends on uncovering the meaning of symptoms, as well as the influence of repressed thoughts and feelings on a person’s psychological well-being (Prochaska & Norcross, 2010). Before we consider the various elements of this therapy we need to briefly look at some of the key concepts of psychoanalytic theory so as to better understand its practice.

Key ideas

Freud was primarily concerned with treating people who had anxiety disorders, and therefore his theory focused on trying to understand the roots of those disorders, which were termed neuroses. According to the psychoanalytic model, neuroses (such as phobias, panic disorders and other anxiety disorders) are caused by unconscious conflicts stemming from early childhood. Freud believed that the underlying forces for all people are life versus death and sex versus aggression (see Chapter 5). People constantly want instant gratification, but this leads to conflict with social (and legal) rules of behaviour. To cope with the anxiety arising from these conflicts, people rely on various defence mechanisms. For example, if a young man is unable to accept that his girlfriend has left him, he may deny this and rationalise her behaviour as being too demanding. He employs the defence mechanisms of denial and rationalisation to cope with the anxiety that his relationship breakup causes him. Defence mechanisms have adaptive value as they help people to cope with anxiety caused by these repressed thoughts and feelings (see Figure 25.2). However, Freud believed that these defence mechanisms can become self-defeating when people use them all the time to avoid facing reality (Corey, 2013).

The key aim of psychoanalytic therapy is, therefore, to make the unconscious conflicts conscious so that people can gain insight into the childhood origins of their problems. However, insight alone does not lead to the resolution of psychological distress. Another task of therapy is to help the client to confront old patterns of behaving in order to effect change, while a third is to integrate the parts of the self that are in conflict with each other (Corsini & Wedding, 2011). Given the nature of the theory underlying this approach, it can be understood why traditional psychoanalytic psychotherapy is not time limited. It usually takes a few years of therapy to help the client uncover and explore the material in their unconscious (Corey, 2013). Hence this type of therapy is long term and relies on several techniques to achieve its aims.

Figure 25.2 The psychoanalytic view of psychological distress

Therapeutic techniques and procedures

Given that the unconscious cannot be accessed directly, the therapist has to infer the content of unconscious conflicts from the client’s thoughts, feelings and behaviour. This means using some of the following techniques and procedures.

Free association

In free association, clients spontaneously express whatever comes into their mind. They report any thoughts or feelings without censoring them, regardless of how embarrassing or minimal they might seem (Corey, 2013). These associations are believed to be important indicators of the unconscious material, which has been repressed. The therapist is then able to analyse and interpret these thoughts and feelings to help clients to identify the unconscious roots of their distress (Corsini & Wedding, 2011).

25.2THE PSYCHOANALYTIC THERAPIST AND THEMBA

As we have discussed, the process of psychoanalytic psychotherapy relies on various techniques to help the client uncover unconscious material, which will eventually lead to change. How could this type of therapy help Themba (see Box 25.1)?

Themba’s history of depression would be understood in terms of repressed childhood difficulties that are now impacting on his current functioning. Thus, within the therapeutic situation, the focus will be on uncovering the material that he has repressed. By delving into his past, Themba may discover the source of his current distress. Perhaps he fears failure because his parents have often ridiculed him. He may have internalised these experiences, which has led to anger and guilt whenever he is unable to meet expectations. These feelings could therefore be the root cause of his depression. In order to make these connections, the therapist will encourage Themba to explore his past by using the various techniques such as free association, interpretation and dream analysis. The therapist therefore listens to the content of what he has to say and explains the symbolic meaning of these thoughts and feelings.

A central focus will be on encouraging the development of the transference relationship between Themba and the therapist. Themba may come to view the therapist as a parent who has high expectations of him. He may react by arriving late for appointments or acting with hostility within the therapeutic situation. The therapist needs to be aware of this and his/her reaction to Themba’s behaviour. By appropriately interpreting the transference relationship, the therapist will help Themba to eventually gain insight into the origins of his depression and of his fear of failure.

Interpretation

One of the key roles of the therapist is to interpret the material that the client brings to the therapeutic situation. Thus, when the client free associates, the therapist strives to explain the hidden meaning of these thoughts and feelings. Similarly, the therapist also analyses the client’s dreams in an attempt to explain their symbolic meaning. While interpretation is central to the analytic process, the therapist does not routinely interpret everything that the client brings to therapy. The interpretation has to be appropriately timed so that the client is able to tolerate and incorporate its content. Thus, the therapist gently offers interpretations progressively so as not to overwhelm the client (Corey, 2013).

Dream analysis

Another way in which unconscious material is accessed is through dream analysis. The therapist interprets the symbolic content of the client’s dreams, thus giving them insight into unresolved conflicts. Freud viewed dreams as being the ’royal road to the unconscious’ because they allow for the expression of unconscious wishes, needs and conflicts. As some thoughts, feelings and needs may be too unacceptable to be consciously expressed, they are repressed in the unconscious and find symbolic expression in the symbolic form of dreams. Thus, the therapist distinguishes between the manifest content, which is the actual content of the dream, and the latent content, which consists of the repressed material that underlies it. It is the latent content that has to be interpreted and shared with the client (Corey, 2013).

Figure 25.3 Dream analysis is used to give insight into unresolved conflicts

Resistance

Even though the therapist endeavours to time the interpretations appropriately, this does not mean that the client is always open to receiving them. There are times when the client offers resistance to the uncovering of unconscious material. Resistance is a key concept in psychoanalysis, and refers to any unconscious defensive strategy that may hinder the process of therapy. It serves the purpose of protecting the client from overwhelming anxiety and pain that may arise once they become aware of repressed feelings (Corey, 2013). Resistance is manifested in various ways, such as arriving late or missing sessions, an unwillingness to relate certain thoughts and feelings during free association, or acting with hostility towards the therapist (Corey, 2013). Essentially, the therapist helps the client to understand and work with the resistance to gain insight into the purpose that it serves. Therefore, the nature of the therapeutic relationship between client and therapist is of paramount importance.

Transference

The therapeutic relationship itself provides a useful tool for helping clients to uncover unconscious material. Transference is an essential element of this relationship and occurs when clients unconsciously relate to the therapist in ways that are similar to significant relationships in their life (Corey, 2013). Thus, as the therapy progresses the therapist is able to observe the impact of early childhood relationships through the way in which a client relates to them within the therapeutic situation. For example, if the client related to his/her parent in a passive, dependent manner, this way of relating may be reproduced in therapy. Thus, transference provides a powerful tool for understanding the impact of the client’s early childhood on his/her current functioning. Therapists also need to be aware of their own unconscious processes as their reactions to their clients (countertransference) may lead to inaccurate interpretations based on the therapist’s own unconscious conflicts (Prochaska & Norcross, 2010).

SUMMARY

•Psychoanalytic approaches aim to help the client gain insight into the underlying causes of emotional difficulties so that they can change their personality and behaviour.

•These approaches are based on the work of Sigmund Freud; he believed that the roots of psychological distress lie within the unconscious.

•Key ideas:

”Neuroses are the basis for various disorders and are caused by unconscious conflicts stemming from early childhood.

”People cope with unconscious conflict through defence mechanisms. These are usually adaptive but may become problematic.

”Psychoanalytic psychotherapy is a long-term approach, working to help clients uncover and explore the material in their unconscious.

•Therapeutic techniques:

”Free association allows clients to express whatever is in their mind; the therapist analyses and interprets this material.

”In interpreting a client’s material, the therapist tries to explain the hidden meaning of these thoughts and feelings.

”Unconscious material can also be accessed through dream analysis. The therapist interprets the latent content of dreams to share this with the client.

”The client may offer resistance to the therapist’s interpretations; the therapist helps the client to understand and work with this resistance to gain insight into the purpose that it serves.

”In the therapist—client relationship, the client is likely to enact past relationships; this is called transference. The therapist uses this to further understand the client’s dynamics. Therapists must also pay attention to their own countertransference.

Cognitive-behavioural therapy

Whereas psychoanalytic psychotherapy is primarily concerned with helping the client to gain insight into unconscious motives, cognitive-behavioural therapy (cognitive therapy) is more action oriented, focusing on the conscious motivation of behaviour. While the identification of the causes of behaviour is important, this does not form the focus of the therapy. Instead, the intervention is aimed at how the relationship between thoughts, feelings and behaviour gives rise to psychological distress (Corey, 2013). We will consider Beck’s (1976) model of cognitive therapy as an example of the cognitive-behavioural approach.

Key ideas

Aaron Beck’s (1976) cognitive therapy highlights the impact that clients’ thinking has on their feelings and behaviour. According to Beck, psychological distress is caused by the way in which people interpret events in their lives. Thus, the way in which they view and understand the world impacts on their feelings and behaviour (see Figure 25.4). This faulty thinking consists of a number of cognitive distortions or biases (Corey, 2013). The aim of therapy is to help the client to become attuned to the internal dialogue, which refers to those negative automatic thoughts that accompany certain feelings and behaviours. By identifying these thoughts, the client is able to judge the appropriateness of the dialogue and, if necessary, change the way that situations are perceived.

Figure 25.4 The cognitive therapeutic view of psychological distress

Cognitive distortions and the roots of psychological distress

Beck (1976) argues that psychological distress is caused by cognitive distortions that occur when clients make errors in reasoning. Thus, they make faulty assumptions about themselves and the world. There are several types of distortions in thinking that lead to emotional difficulties (Beck, Rush, Shaw & Emery, 1979):

•Arbitrary inferences occur when a client draws conclusions about themselves and the world without any supporting evidence in objective reality. For example, a client may believe that she will not succeed at university because she is incapable of achieving anything.

•Selective abstraction occurs when clients draw conclusions based on a specific detail of an event while ignoring any other disconfirming information. For example, they may only focus on their failures while ignoring those occasions when they have been successful.

•Overgeneralisation occurs when the client holds extreme ideas as a result of an isolated incident and applies these to other situations. For example, if a client has experienced difficulty in understanding a prescribed reading for one course, then he may conclude that he is not at all suited to academic study.

•Magnification and minimisation occur when the client perceives a situation either in an exaggerated or understated manner. For example, if the client has experienced difficulties in one of her practicals, she may consider herself incapable of eventually practising as a professional in this field. In this way the situation is magnified. Similarly, the client may be under threat of exclusion from university but says this is no problem, thus minimising the situation.

•Personalisation occurs when the client relates external events to himself even when there is no logical reason to make this connection. For example, if a tutor refuses to supply the class with additional information for an assignment, he may interpret this as the tutor’s dislike of him.

•Labelling occurs when a client overgeneralises and defines herself in terms of her shortcomings. For example, if the client has failed a test, she may believe that she is worthless.

•Polarised thinking involves thinking and interpreting situations in extremes. Consequently, the client may think in all-or-nothing terms. For example, he may perceive himself as either a brilliant learner or a complete academic failure.

The cognitive distortions outlined above provide us with some indication of how faulty interpretations of situations can lead to psychological distress. How, then, does the cognitive therapist help the client to change distorted thinking? This is discussed in the next section.

Therapeutic techniques and procedures

The techniques employed by the cognitive therapist are psycho-educational, which means that therapy is viewed as a learning process. Not only do clients gain insight into the negative automatic thoughts that underlie their feelings and behaviour, but they also learn new ways of perceiving and interpreting situations (Corey, 2013).

25.3THE COGNITIVE THERAPIST AND THEMBA

Beck’s (1976) approach was originally developed as treatment for depression, and therefore we can briefly consider how the cognitive therapist could help Themba (from boxes 25.1 and 25.2).

Themba’s depression can be understood as being triggered by the negative view that he has of himself. He blames his experiences at university on personal shortcomings and is unable to consider alternative explanations for events. He also interprets all his experiences in a negative manner and as such selectively abstracts from situations to support the views that he has about himself. Themba’s gloomy vision of the future also serves to deepen his depression, as he does not allow himself to have any positive thoughts about it. In addition, the physical symptoms that he is experiencing serve to heighten his negative self-perceptions.

To be able to help Themba, the therapist will challenge his negative thoughts by asking him to provide evidence for these beliefs. Thus he may be asked to list reasons why he views himself in this way. He may also be asked to provide evidence to dispute this view of himself. In so doing, the therapist aims to show Themba that it is his distorted perceptions and not reality itself that is the cause of his depression. One of the aims of therapy may be to encourage Themba to stay at university by helping him to deal with those thoughts and feelings that prevent him from pursuing his studies. To encourage him to become more active and to counter his lethargy, homework tasks may be assigned that include setting up an activity schedule that requires him to perform certain tasks. Themba also feels overwhelmed by the demands of his course and often this feeling is exaggerated. As a result, he reacts by not doing anything. The therapist may help him to prioritise tasks and to break down his work into manageable units. In this way, he may feel some sense of mastery and be able to see how the magnification of his feelings leads to distorted perceptions about his abilities.

Therapeutic techniques are essentially task oriented and clients are encouraged to actively monitor those thoughts that accompany psychological distress. This is often in the form of homework where clients may be asked to keep a diary of their automatic thoughts. The homework is presented as an experiment to see where negative automatic thoughts occur and, in recording those situations, clients are able to see both the content and context of those thoughts (Corey, 2013). The therapist also challenges the negative automatic thoughts by asking clients to provide evidence for the beliefs that they have about themselves.

In order to address the cognitive distortions that cause distress, the therapist helps clients to explore them. They are encouraged to replace negative ways of viewing the world with more positive ones. In addition, they are encouraged to perceive themselves as more competent and capable. The homework tasks enable the testing of beliefs in real-life situations. In this way, faulty thinking is also challenged. Homework also serves the purpose of teaching clients new skills, such as relaxation methods and social skills (Beck et al., 1979).

SUMMARY

•Compared to psychoanalytic psychotherapy, cognitive-behavioural therapy is more action oriented.

•The focus of the therapy is on the client’s automatic thoughts and how the relationship between thoughts, feelings and behaviour gives rise to psychological distress.

•Key ideas:

”For Aaron Beck, faulty thinking (cognitive distortions) impacts on people’s feelings and behaviours.

”Cognitive distortions include arbitrary inferences, overgeneralisation, magnification and minimisation, personalisation, labelling and mislabelling, and polarised thinking.

•Therapeutic techniques:

”Psycho-educational, task-oriented techniques allow clients to gain insight into the negative automatic thoughts that underlie their feelings and behaviour.

”The therapist challenges the negative automatic thoughts by asking clients to provide evidence for their self-beliefs.

”Clients thus learn new ways of perceiving and interpreting situations and perceive themselves as more competent and capable.

”Therapy is time limited with a specific problem-solving focus.

Cognitive therapy is aimed at helping clients to deal actively with psychological distress. The therapist is directive and actively encourages clients to change the way situations are interpreted. This therapy is therefore time limited as it has a specific problem-solving focus (Beck, 1976). Thus, while the psychoanalytic therapist views clients’ symptoms as indicative of underlying conflicts, the cognitive therapist views faulty thinking as the problem. This approach to therapy therefore advocates that it is more important to actively identify and change maladaptive thoughts and beliefs than to merely understand what causes them.

Experiential and relationship-oriented therapies

Existential therapy

Existential therapy describes a philosophical approach rather than a specific form of therapy or set of techniques. Corey (2013) notes that an existential approach rejects the determinism which is characteristic of both psychoanalytic and radical behaviourist approaches. Rather, it sees people as free to choose their life path. Thus this approach assists people with the ’big’ questions about life: why am I alive? What is my purpose? What is freedom and what should I do with it? It argues that people are not victims of circumstance and it aims to challenge clients to take responsibility for their choices and actions.

Existentialists focus on ’the human condition’. They see people as grappling with ’the dilemmas of contemporary life, such as isolation, alienation, and meaninglessness’ (Corey, 2013, p. 133). People are constantly changing and evolving, and in the process they continually have to try to make sense of their existence. For the existential approach, the basic dimensions of the human condition are as follows:

•The capacity for self-awareness. Self-awareness is based on freedom, choice and responsibility (Corey, 2013). We can choose to expand self-awareness and thereby grow as people, but once we have done this, it is not possible to go back to a state of lesser awareness.

•Freedom and responsibility. People often try to evade responsibility for their actions (’It’s not my fault — I was born like this’), but existentialists say we are free to choose and to act on our choices. That freedom entails responsibility and if we evade such choices, we suffer existential guilt. Rather, we should be authentic and lead lives that are true to what we believe is meaningful and valuable.

•Identity and relationship. Preserving one’s unique identity is an important aspect of being human. However, many of us rely on input from others rather than trusting our own answers to life’s conflicts (Corey, 2013). The question of relationship refers to the paradox of human existence — we are both essentially alone in the world (we are born and die alone) but we are also essentially dependent on relatedness with others for a sense of our significance in the world (Corey, 2013).

•The search for meaning. It is distinctly human to wonder about the purpose of our existence on Earth and these existential conflicts are often the underlying reason why people enter therapy (Corey, 2013). When people change, they often struggle to establish new meaning systems and so struggle with a sense of meaninglessness. In this condition, people feel that their lives are empty; existential therapy assists people to engage deeply with others and through this, find meaning.

•Anxiety as a condition of living. Existential anxiety results from the realisation of our struggle for survival, of our aloneness in the world and the facts that we make mistakes and will die. Some degree of anxiety is normal and adaptive (e.g. it is helpful to be aware that you need to study for exams), but neurotic anxiety can be paralysing (Corey, 2013).

•Awareness of mortality. For existentialists, the reality of death is what makes living significant (Corey, 2013). Humans are alone among animals in being able to perceive that death is inevitable. In therapy, therefore, death is not avoided but rather seen as reason and motivation to engage fully in life.

Relationship-oriented therapy

Corey’s (2013) definition of psychotherapy emphasises the importance of the therapeutic relationship in bringing about change within the client. While the importance of the relationship is emphasised in both the psychoanalytic and cognitive approaches, particular techniques are key factors in helping clients to bring about change in their lives. The person-centred approach advocated by Carl Rogers (1951) departs from this focus on theory and technique. This approach emphasises the centrality of the personal qualities of the therapist and the quality of the therapeutic relationship in helping the client to change. This approach is rooted in humanistic philosophy, which believes that each person has the potential to self-actualise (to express his/her unique self), given the proper environment. Thus, the central aim of person-centred therapy is to help clients to achieve their potential by providing a supportive emotional therapeutic climate.

Figure 25.5 Carl Rogers

Key ideas

The humanistic philosophy within which this approach is located advocates a positive view of human nature. The belief is that the client possesses the inherent capacity to become psychologically healthy when the correct emotional climate is provided. The therapeutic relationship is viewed as providing the client with the mechanism to achieve this goal (Rogers, 1951). An important aspect of this approach is that the client and not the therapist directs the process of therapy. Rogers rejects the notion of the therapist as expert. Instead, he argues that clients are the experts on their distress and should therefore be the ones to direct the process of healing.

Rogers’ (1951) conception of the causes of psychological distress differs from the approaches discussed previously. He argues that distress is caused by incongruence, which is the discrepancy between the client’s self-perception and reality. Anxiety arises when the client is confronted with feedback from objective reality that is at odds with the self-concept. The client then employs defence mechanisms in order to protect the self from this anxiety (see Figure 25.6). Rogers views these defences as maladaptive because they protect the client’s distorted self-concept. He believes that a supportive environment can help the client to address this incongruence.

Figure 25.6 The person-centred view of psychological distress

As an example, consider the case of Sithembile, who is a student who is struggling academically. If she believes that she is a resilient person who is coping well with the demands of university, negative feedback from others as well as the reality of her poor marks may result in anxiety. She may rely on defence mechanisms or she may distort reality to deal with the anxiety. This will result in her being unable to actualise and achieve her potential. Within a person-centred approach, this student would be helped to achieve a self-concept that is more realistic so that she is able to appreciate herself. The therapeutic situation will enable her to explore and integrate various feelings that she has previously been unable to acknowledge.

Therapeutic techniques and procedures

As mentioned earlier, the person-centred approach does not emphasise the centrality of techniques in helping clients to change (Corey, 2013). Instead, the focus is on providing a therapeutic climate that will enable clients to express their sense of self. Thus the primary responsibility for healing and change is placed on the client. However, Rogers (1961) makes it clear that there are certain core conditions within the therapeutic relationship that are ’necessary and sufficient’ for the client to change:

•Congruence refers to the genuineness that the therapist expresses in the relationship. Thus the therapist has to be authentic in his/her reactions to the client. There must be a genuine acknowledgement of feeling regarding the client in order to enhance honest communication. The therapist may need to express certain feelings in an attempt to be authentic, but this should not be at the expense of the client’s feelings. Congruence implies that the therapist is willing to confront his/her own feelings so as to provide the client with a positive role model, as well as a growth-enhancing experience.

•Unconditional positive regard refers to the therapist’s unconditional acceptance of the client as a person. This means that the therapist is non-judgemental in caring for the client even when he/she does not approve of the client’s behaviour. The central concern is for the client as a human being, regardless of the thoughts, feelings and behaviour that are expressed within the therapeutic situation.

•Accurate empathy refers to understanding the client’s thoughts, feelings and experience from the client’s perspective. This requires that the therapist must share the client’s subjective experience so that his/her understanding can be reflected back to the client. When the therapist accurately empathises with the client, the probability of change is greatly enhanced. Empathy is more than a reflection of those thoughts and feelings that are obvious to the client. When the therapist is accurately attuned, he/she is able to reflect those feelings that underlie the content. Thus the client gains insight into the roots of the incongruity between his/her self-concept and reality. By accurately acknowledging these feelings, the therapist helps the client to resolve the incongruity and effect constructive change.

Rogers (1961) believes that a supportive therapeutic relationship that contains the above three elements is fundamental in helping clients to change. The techniques that will help clients to better understand their feelings are listening, reflecting and providing clarification. The person-centred approach has evolved over the years since it first emerged and it remains open and flexible to change (Corey, 2013).

SUMMARY

•Existential therapy reflects a philosophical approach rather than a specific form of therapy or set of techniques.

•This approach emphasises free will and how people deal with the ’big’ questions about life.

•The human condition sees people grappling with the challenges of contemporary life, such as

”capacity for self-awareness

”freedom and responsibility

”creating identity and establishing meaningful relationships

”the search for meaning and purpose ” anxiety as a condition of living

”awareness of mortality.

•Relationship-oriented therapy (Carl Rogers) emphasises the importance of the therapeutic relationship and the personal qualities of the therapist in bringing about change within the client. This approach grew from humanistic philosophy, which believes that each person has the potential to self-actualise.

•Key ideas:

”This approach advocates a positive view of human nature, seeing people as basically healthy.

”The client, and not the therapist, directs the process of therapy.

”Psychological distress is caused by incongruence between the client’s self-perception and reality.

•Therapeutic techniques:

”The client has primary responsibility for healing and change.

”To facilitate this, the therapist must provide the core conditions within the therapeutic relationship that are ’necessary and sufficient’ for the client to change: congruence, unconditional positive regard and accurate empathy.

25.4THE PERSON-CENTRED THERAPIST AND THEMBA

Going back to Themba, in terms of the person-centred approach, his personal distress is seen as being due to the incongruence between his self-concept and reality. Through the process of therapy, Themba may come to realise that his perception of himself as a conscientious student is at odds with his lecturers’ perception of him. They may perceive him as someone who does not apply himself to his studies because he procrastinates and often misses deadlines. As a result, he does not achieve good marks in his courses. Themba feels threatened and anxious when confronted with this feedback from his lecturers. He responds by avoiding his studies and withdrawing into himself. In this way, he does not have to face the reality of his poor academic performance. The incongruence between Themba’s self-concept and the feedback from his lecturers is at the heart of his current distress. He realises that a problem exists and that he needs to explore options for change.

The person-centred framework provides Themba with an opportunity to explore these feelings. The therapist provides a warm and caring environment within which he feels free to express these feelings. The therapist listens intently to his thoughts and feelings, and clarifies and reflects these back to him. By being genuine and accepting him unconditionally, the therapist creates a climate that will encourage Themba to examine his sense of self. Essentially, the therapist aims to provide Themba with a safe experience, which will increase his confidence in his abilities to discover an alternative way of being. Ultimately, he will be empowered to take responsibility for directing the course of his life.

Systems and postmodern approaches

These approaches to psychotherapy include some that have evolved from the three previous approaches discussed in this chapter. These reflect wider developments in the ways in which psychological distress and healing are construed. In particular, they pay closer attention to understanding people from within their contexts and how this has influenced their development (Corey, 2013). The following therapies have developed in response to various philosophies.

Social constructionist narrative therapy

Social constructionist narrative therapy draws on social constructionist principles that regard an individual’s experience as being shaped and informed by the context within which they live (White & Epston, 1990). Social constructionism claims that knowledge does not exist independently of the knower (Prochaska & Norcross, 2010). Thus, people construct their own knowledge relative to their culture and language. In this way, broader cultural narratives (or stories) impact on personal narratives providing meaning to personal life experiences (Freedman & Combs, 1996; Morgan, 2000).

Drawing on these principles, narrative therapists therefore question the notion that psychological distress is a function of problematic internal processes. Instead they believe that personal distress can be understood in terms of dominant cultural narratives. People live their lives according to the stories they tell about themselves (’I am a kind persion’) and those told about them by others (’She can be so mean at times’) (Corey, 2013). These stories need to be deconstructed so as to decrease the impact they have on the client’s life (Freedman & Combs, 1996; Morgan, 2000). For this reason, therapy focuses on externalising the problem such that the distress is seen as existing outside of the client. Thus the person is not the problem; the problem is the problem. Essentially, the therapist aims to help clients to re-author their stories so that there are alternate, more positive ways of relating to the world. An important aspect of this approach is that clients are the experts on their stories and the therapist collaborates with them in re-authoring them (White & Epston, 1990; Morgan, 2000).

Solution-focused brief therapy

Solution-focused brief therapy (SFBT) has been growing in popularity in recent decades, especially as it fits a context in which health care resources are limited (Rothwell, 2005). It is based on social constructionist approaches (Rothwell, 2005). In contrast to a psychoanalytic approach, it is future focused and respects the client’s aims for therapy. It has a positive focus and aims to empower clients and rapidly reduce their distress (Wehr, 2010).

In SFBT, the therapist asks questions to help clients envision what their desired future might entail (e.g. ’If a miracle happened and you stopped procrastinating work on your assignments, what would be different in your life?’). The aim of this is to help clients develop a detailed vision of their desired outcomes, and also to ’identify their strengths, resources and times when the problem is not in evidence’ (Rothwell, 2005, p. 402). The therapist may also set tasks for clients, including asking them to do more of what is already working in their lives. Sessions end with the therapist complimenting clients based on what emerged in their session. A number of studies have demonstrated the effectiveness of this approach (Rothwell, 2005; Wehr, 2010).

Feminist therapies

Feminist critiques of traditional psychotherapy argue that mainstream models have failed to address the impact of the imbalance of power in society on women’s (and men’s) lives (Brown, 1994; Worell & Remer, 2003). Mainstream models locate psychological distress internally, thus making it incumbent on the client to change, but this ignores how structural inequality and gender oppression can adversely impact on psychological well-being (Corey, 2013; Enns, 2000). There are various types of feminist therapies, and some have included mainstream ideas, while others adopt a more diverse approach.

What is common to all of these is the feminist principles that underlie them. Feminist therapists acknowledge that personal distress has political roots, and thus move away from the intrapsychic focus of traditional models. These therapies also acknowledge multiple forms of oppression, which take into account that women (and men) can be oppressed in terms of gender, race, class, sexual orientation and so on. Another commonality is that all feminist therapies advocate egalitarian therapeutic relationships where clients and therapists collaborate when dealing with difficulties. Feminist therapies therefore aim to eradicate all forms of oppression through helping women to empower themselves. Thus women are empowered to challenge and change the status quo at personal and societal levels (Worell & Remer, 2003).

One of the most controversial challenges that face feminist therapists is whether men can be clients or therapists in this modality. Corey (2013) suggests that it is a misconception that if therapy is pro-women, then it must be anti-men. While feminists are divided on this issue, it makes sense that male therapists can include these principles in their work. Also, feminist psychotherapy approaches are applicable to male clients, to clients from diverse backgrounds and those working for social justice (Enns, in Corey 2013).

Systemic therapeutic approaches

Most intervention models focus on the individual both in terms of locating the problem, and bringing about change. In looking beyond individuals to the context within which they operate, systemic approaches consider the family as the site of both problem and intervention. This is often a difficult shift in perspective for Western therapists trained in individualistic approaches (Corey, 2013). A family systems approach is concerned with how the interactions between family members impact on the individual. Thus family therapists are concerned with what happens between members of a family as opposed to what is happening in the internal world of the individual.

SUMMARY

•Systemic and postmodern approaches to psychotherapy pay closer attention to understanding people from within their contexts.

•Narrative therapy is a social constructionist approach; thus it understands that people construct their own knowledge relative to their culture and language:

”Broader cultural narratives impact on personal narratives (or stories).

”Psychological distress is thus not a function of problematic internal processes; rather, personal distress is driven by dominant cultural narratives.

”Therapy aims to help the client re-author their stories to achieve more positive ways of relating to the world.

•Solution-focused brief therapy (SFBT) is also based on social constructionism and is future focused:

”In SFBT, the therapist uses questions to help clients develop a detailed vision of their desired future.

”Clients’ strengths and resources are also identified and built on.

•Feminist therapies aim to redress the effects of the social imbalance of power on women’s (and men’s) lives; they see the political roots to people’s personal distress:

”Therapy is collaborative and egalitarian.

”Male therapists and clients can also benefit from feminist approaches.

•Systemic approaches focus on how interactions occur in the family and systemic context rather than in the internal world of the individual. Family therapy is therefore aimed at addressing the dysfunction of the various subsystems and the family as a whole.

The family system is comprised of various subsystems that are interrelated in such a way that change or imbalance in one subsystem impacts on other subsystems and the family as a whole. There are ’rules’ and processes that guide the functioning of the family and these may need to change depending on the demands faced by the system. Systems also go through transitions, and the way in which the family responds to these is indicative of its current functioning. Family therapy is therefore aimed at addressing the ’dysfunction’ of the various subsystems and the family as a whole. Thus interventions focus on treating the family and not the individual who is symptomatic of the family’s problems (Minuchin, 1974).

The effectiveness of psychotherapy

In our discussions of the different therapeutic approaches, we have considered how they may be used to alleviate Themba’s psychological distress. A pertinent question at this point may be whether these approaches are effective in achieving this aim. The issue that faces the advocates of various types of therapy is whether or not psychotherapy actually works. Is psychotherapy the talking cure that Freud intended it to be, and if so, how does one measure if the client has been cured? This dilemma has seen considerable attention in recent decades as psychotherapy. There has been an increased effort towards therapeutic efficiency and accountability (Reid & Eisman, 2006, in Corsini & Wedding, 2011). However, this effort is time consuming and challenging (Corsini & Wedding, 2011), especially given the very private and subjective nature of psychotherapy. Numerous efforts have been made to prove empirically that certain therapies are indeed effective, and in some instances researchers have tried to prove that some therapies are superior to others. However, as we will see, this is a complex issue, and to date, most studies have focused on evaluating therapies within an experimental context, which militates against the inclusion of a wide range of therapies.

Kazdin (2008) notes the context within which the focus on evidence-based practice has grown. He particularly highlights the role of legislation and of third-party payers like medical aids. The latter are having an increasing say in which therapies will be paid for and at what rate (Kazdin, 2008). Kazdin (2008, p. 157) goes on to argue that ’the best practice will continue to be based on the best science’. He suggests that research needs to focus more on change processes, especially in terms of how change can be activated. Research should also focus on moderators of treatment — how do they make a difference, and if so, to all kinds of treatment? There should also be more qualitative research and the patient’s progress monitored as systematically as possible (Kazdin, 2008).

The role of indigenous therapies in an African context

Cross-cultural issues in therapy

Our discussion thus far has focused on the psychotherapeutic approaches that form the core of Western psychological models of intervention. We have applied these approaches to a case study of Themba who is a young, black South African male so as to see how each approach can alleviate his distress. However, we have not considered the impact of culture (in other words, ethnic or racial background) on Themba’s interaction with the various therapists. This may create the impression that culture is not important and that Western modes of intervention are readily transferable to any sociocultural context. But an important aspect of therapeutic intervention is the acknowledgement of the impact of the cultural framework of both client and therapist (Corsini & Wedding, 2010). Clients’ experience of the problem is embedded in their cultural experience. Similarly, the therapist’s cultural background influences their interaction with clients and he/she needs to be cognisant of this (Corey, 2013).

There are also other factors, such as gender and class, which need to be considered. An acknowledgement of the impact of culture, class and gender enables the therapist to gain a holistic view of clients and militates against the therapist making undue assumptions of clients and their problems (Corsini & Wedding, 2011). Thus working cross-culturally requires a distinct awareness as well as specific skills (Botha & Moletsane, 2012). It is no longer viable in contemporary society to ignore the issue of culture (or gender or class). These considerations have led to the development of theories and techniques for multicultural or cross-cultural therapies (Prochaska & Norcross, 2010), and represent attempts by mainstream psychotherapeutic models to become more applicable to non-Western settings (Corey, 2013). The central ideas of these models are similar.

25.5HOW DO WE ASSESS THE EFFECTIVENESS OF PSYCHOTHERAPY?

Our discussion has centred on a number of diverse therapeutic approaches but, as we have seen, there are more than 400 types of therapy that are currently being practised (Corey, 2013). How do we assess the effectiveness of these approaches? Seligman (1995) says that there are two ways in which researchers have tried to measure the outcomes of psychotherapy, namely efficacy studies and effectiveness studies. The former is more popular and has been the primary manner in which researchers have evaluated the outcomes of certain types of psychological intervention.

In treatment efficacy studies, efforts are made to improve the methodological quality of the research (Hunsley, Elliott & Therrien, 2013). Thus, studies are conducted in an experimental situation where participants are randomly assigned to experimental and control conditions so as to assess if a particular type of therapy is effective in treating a particular disorder. The experimental group is required to subscribe to the therapy for a set number of sessions and the treatment is short-term and time limited as researchers want to establish whether a particular intervention actually works. In these studies only participants with one diagnosis are allowed because multiple diagnoses militate against the assessment of the effectiveness of the therapy for a particular disorder (Seligman, 1995). Thus, if there is an improvement in the psychological well-being of the experimental group, then it is concluded that the therapy works and it is given greater legitimacy.

Seligman (1995) says that efficacy studies have become the gold standard by which the utility of therapies is assessed. But while there is value in using this method to assess the usefulness of therapies for the treatment of certain disorders, it becomes problematic regarding the outcomes of long-term therapies such as psychoanalysis. Efficacy studies typically evaluate therapies that are time limited, such as cognitive therapy. It would be extremely difficult to assess psychoanalysis in this manner, as this type of therapy is dependent on the uncovering of unconscious material — a process that cannot be confined to a limited number of sessions. In addition, the analytic process may result in many issues being raised in therapy and consequently more than one diagnosis may be made.

Does this mean that we are unable to assess the utility of psychoanalysis or are there other means by which we can achieve this? Hunsley et al. (2013) argue that both efficacy and effectiveness studies need to be undertaken. If efficacy looks at how the treatment will work in theory, effectiveness studies attempt to locate themselves where the actual treatments are happening and using therapists who are actively engaged in providing such services.

One kind of effectiveness study involves using a survey method, thus asking respondents to report on their actual experiences in therapy. Seligman (1995) refers to the Consumer Reports study, which was published in the US in 1995. This study surveyed the experiences of several thousand people with regard to their experiences of psychotherapy. The questions ranged from details regarding the type of therapy engaged in and the competence of the therapist, to the reasons for terminating the therapy. The study concluded that people benefited from psychotherapeutic intervention and that long-term therapy was more effective than short-term interventions.

Seligman (1995) argues that this survey method allows us to gain a clearer view of the effectiveness of a wide range of therapies. However, there are methodological flaws associated with this type of research. Among other problems, there were three notable ones in this study: there were no control groups with which to compare the sample, the method relied on the participants’ self-reports (which are highly subjective), and participants were asked to report retrospectively on their emotional states. A more recent study (Hunsley et al., 2013) used meta-analyses of studies on a number of common disorders. Hunsley et al. (2013, p. 5) argue that ’meta-analyses are likely to provide the most current and thorough overview of a research area’ and that using advanced statistical techniques provides ’the most accurate synthesis of results obtained from multiple studies’.

Effectiveness and efficacy studies have been significant in the evidence-based practice movement. This ’international juggernaut racing to achieve accountability in all forms of health care’ (Prochaska & Norcross, 2011, p. 521) is not without its problems and criticisms. It is widely accepted that sound practice should be based on evidence; however, it is somewhat more complicated to reach agreement on what counts as evidence (Prochaska & Norcross, 2011). In addition, Prochaska and Norcross (2011) suggest that research and efforts towards evidence-based practice have neglected the therapy relationship. There is wide support for the idea that much of the outcome in psychotherapy is attributable to factors in the therapy relationship and it is critical that these aspects are not sidelined in efforts to improve accountability in psychotherapy.

Indigenous therapies

The attempts at adapting mainstream models of intervention so as to be applicable to non-Western cultures do not imply that these models are the best or only way of helping people. Western notions of psychological distress, and the concomitant modes of helping, reflect Western ideas and values that may not always be suitable for other cultural contexts (Botha & Moletsane, 2012). There are other forms of non-professional intervention that people turn to in times of distress. The World Health Organization (2003) says that ’traditional medicine refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singly or in combination to treat, diagnose and prevent illness or maintain well-being’.

Of interest to us are the folk-sector healers who are non-professional healers who use a variety of techniques such as rituals, herbal remedies, symbolic healing and spiritualism to help clients in distress (Kleinman, 1980; White, Jain & Giurgi-Oncu, 2014). Swartz (1998) identifies two types of folk healing in use in southern Africa, namely, indigenous healing and religious healing.

Regarding indigenous healing, there is diversity in terms of the type of healing offered and the contexts within which such healing occurs. For example, in indigenous healing in KwaZulu-Natal, a distinction is made between an isangoma (diviner) and an inyanga (doctor or herbalist). The isangoma is a person who has been chosen by the ancestors to become a healer, while the inyanga is a dispenser of herbal remedies (Ngubane in Swartz, 1998). The way in which distress is conceptualised and treated will depend on the healer’s orientation.

In indigenous healing, psychological distress is attributed to disturbances in the physical realms (nature), the social realms (family and other relationships) and the supernatural realms (bewitchment, spirit possession) (Botha & Moletsane, 2012). For example, Themba’s emotional state and his failure to achieve may be seen to have been caused by a curse placed on him by a jealous neigh-bour who is envious of his university studies. His distress is not viewed as having internal roots. Instead, it is something that has been thrust upon him by external forces. Themba may seek help from an indigenous healer in order to establish how to deal with his misfortune. The intervention may require the use of herbal remedies or rituals to alleviate his distress.

Religious healing is the second type of healing that falls within the folk sector. This type of healing mostly involves prayer, laying-on of hands, and providing holy water or ash (Truter, 2007). Swartz (1998) says that the ’African independent churches’ employ a mixture of Christian beliefs and practices and indigenous healing. In some churches there is a significant emphasis on elements such as spirit possession, while others emphasise charismatic Christian aspects. This type of healing appeals to many people as it provides spiritual solutions to their problems.

Swartz (1998) also states that folk-sector healing often occurs within a communal setting. Thus the distress and healing is shared with others. This approach differs from the individualised Western dyadic models that were discussed earlier in this chapter. Folk-sector healing reflects certain spiritual values that are cherished in African cultures.

SUMMARY

•The effectiveness of psychotherapy is receiving increasing attention in the current focus on evidence-based practice. This is driven by demands for accountability from government and third-party funders. However, this research is time consuming and difficult.

•We need to think critically about the applicability of Western models of therapy in multicultural contexts. The cultural background of both the client and the therapist impact on their understanding and treatment of the problem.

•Gender and class differences also need to be considered.

•People have been using indigenous healing methods for many generations. Non-professional folk-sector healers use a variety of techniques such as rituals, herbal remedies, symbolic healing and spiritualism.

•In southern Africa, there are diverse kinds of healing offered including herbal remedies and rituals.

•In indigenous healing, psychological distress is attributed to disturbances in the physical social realms and supernatural realms.

•In religious healing, there is emphasis on aspects like spirit possession and charismatic Christian aspects.

Conclusion

This chapter focused on four core approaches to helping patients alleviate their psychological distress. However, these approaches were conceptualised within particular Western contexts and seek to address the problems of individuals living within these environments. Therefore, while models of psychotherapy have utility in addressing the psychological needs of individuals, these models may be limited in meeting South Africa’s large-scale mental health needs. In addition, we need to ask ourselves whether Western models of psychological distress and therapeutic intervention can and should be transposed onto the African context. We cannot uncritically accept these notions even if individual psychotherapy represents one of the core competencies in which psychologists are trained.

The search for theory and practice that takes account of our particular sociopolitical and economic context is one that challenges mental health practitioners in South Africa today. As a result, psychologists are redefining the parameters of therapy so as to make it more socially relevant and accessible to people. (See Chapter 26 for a discussion of other approaches within a community mental health approach.)

KEY CONCEPTS

accurate empathy: a core condition for therapeutic change according to the person-centred approach that refers to understanding the client’s thoughts and feelings from the client’s perspective

arbitrary inferences: a cognitive distortion that occurs when the client draws conclusions about him-/herself and the world without real evidence

automatic thoughts: personalised ideas that occur in people in response to particular stimuli

cognitive-behavioural therapy: a type of therapy that focuses on the conscious motivation of behaviour

cognitive distortions: the drawing of faulty assumptions about oneself and the world as a result of errors in reasoning

congruence: a core condition for therapeutic change according to the person-centred approach that refers to the genuineness that the therapist expresses in the relationship

countertransference: an important process in psychoanalytic psychotherapy that refers to the way in which the therapist reacts to his/her client’s transference

defence mechanisms: ways in which people cope with the anxiety caused by repressed thoughts and feelings

dream analysis: a therapeutic technique in psychoanalytic psychotherapy where the therapist interprets the symbolic content of the client’s dreams, thus giving him/her insight into unresolved conflicts

effectiveness studies: studies that employ a survey method asking respondents to report on their actual experiences in therapy

efficacy studies: studies that are conducted in an experimental situation so as to assess if a particular type of therapy is effective for treating a particular disorder

folk-sector healers: people who are non-professional healers and who use a variety of techniques such as rituals, herbal remedies, symbolic healing and spiritualism to help clients in distress

free association: a therapeutic technique in psychoanalytic psychotherapy where the client spontaneously expresses whatever comes to mind

incongruence: the discrepancy between a client’s self-perception and reality that causes distress

indigenous healing: a type of folk healing in use in southern Africa where psychological distress is attributed to disturbances in the physical realm, the social realm and the supernatural realm

interpretation: a therapeutic technique in psychoanalytic psychotherapy where the therapist strives to explain the hidden meaning of his/her client’s thoughts, feelings and/or dreams

labelling: a cognitive distortion where a client defines him-/herself in terms of his/her shortcomings

latent content: that part of a dream that consists of the repressed material that underlies it

magnification: a cognitive distortion where a client perceives a situation in an exaggerated manner

manifest content: the actual content of a dream

minimisation: a cognitive distortion where a client perceives a situation in an understated manner

neuroses: phobias, panic disorders and other anxiety disorders that are caused by unconscious conflicts stemming from early childhood

overgeneralisation: a cognitive distortion where a client holds extreme ideas as a result of an isolated incident and applies this to other situations

person-centred therapy: a type of therapy that emphasises the centrality of the personal qualities of the therapist and the quality of the therapeutic relationship in helping the client to change

personalisation: a cognitive distortion where a client relates external events to him-/herself even when there is no logical reason to make this connection

polarised thinking: a cognitive distortion that involves thinking and interpreting situations in extremes

psychoanalytic psychotherapy: a type of therapy that is largely concerned with helping a client to gain insight into the underlying causes of emotional difficulties in order to bring about changes within personality and behaviour

psychotherapy: an ’engagement’ between two individuals, namely the therapist and the client, who are focused on bringing about change within the client via the therapeutic relationship

religious healing: a type of folk healing in use where churches employ a mixture of Christian practices and indigenous healing

resistance: a key concept in psychoanalysis, which refers to any unconscious defensive strategy that may hinder the process of therapy

selective abstraction: cognitive distortion in which the person draws conclusions on the basis of isolated details, ignoring other information

transference: when a client involved in psychoanalysis unconsciously relates to the therapist in ways that are similar to significant relationships in his/her life

unconditional positive regard: a core condition for therapeutic change according to the person-centred approach that refers to the therapist’s unconditional acceptance of the client as a person

EXERCISES

Multiple choice questions

1.Thabo experiences his therapist as authoritative and emotionally distant. In many ways their relationship mirrors the relationship that he had with his father. This is an example of:

a)resistance

b)projection

c)transference

d)countertransference.

2.Free association is a psychoanalytic technique in which the client:

a)makes connections between the conscious and unconscious

b)spontaneously talks about whatever comes to mind

c)feels free to question the therapist on personal matters

d)censors the thoughts and feelings that are shared with the therapist.

3.Since talking about the death of his mother, Simphiwe consistently arrives late for sessions with his therapist. This is an example of:

a)denial

b)grief

c)resistance

d)countertransference.

4.Psychological distress is caused by the way in which people interpret events in their lives. This understanding underpins the approach to psychotherapy.

a)psychoanalytic

b)cognitive-behavioural

c)person-centred

d)cognitive.

5.Carol believes that she is a complete failure because she failed a maths test at school. Her belief is held in spite of the good marks that she attains in her other subjects. This belief is an example of:

a)personalisation

b)selective abstraction

c)magnification

d)minimisation.

6.When the client is taught new ways of perceiving and interpreting situations in order to bring about change, this approach is seen as:

a)dynamic

b)psychoeducational

c)empathic

d)homework.

7.Jim tells the therapist that he has committed a crime and feels guilty about it, and she responds by saying that she does not judge him even though she does not agree with what he has done. This caring, non-judgemental attitude expressed by the therapist toward the client is called:

a)acceptance

b)empathy

c)unconditional positive regard

d)congruence.

8.The discrepancy between a person’s self-concept and reality is what Rogers calls:

a)psychological distress

b)anxiety

c)incongruence

d)genuineness.

9.There are certain ’core conditions’ in the therapeutic relationship that are__________for the client to change.

a)necessary and sufficient

b)fundamentally important

c)necessary

d)therapeutically important.

10.Non-professional healers who use rituals, herbal remedies and symbolic healing fall within the framework as opposed to a Western psychotherapeutic framework.

a)lay-counselling

b)indigenous-healing

c)religious-healing

d)spiritual-healing.

Short-answer questions

1.Discuss any three of the following four therapeutic techniques used in psychoanalytic psychotherapy: free association, interpretation, dream analysis and transference.

2.Explain what a cognitive distortion is and define and give an example of each of the following: overgeneralisation, personalisation and labelling.

3.How does the person-centred approach conceptualise psychological distress? Illustrate your answer by means of a diagram.

4.Name and describe the ’core conditions’ suggested by Rogers (1961) that are necessary and sufficient for the client to change.

5.What are ’folk-sector healers’ and how do they differ from psychotherapists trained in Western models?