Psychotherapy is a voluntary relationship between the one seeking treatment (client) and the one who treats (therapist). The purpose of the relationship is to help the client solve the psychological problems being faced by her/him. It aims at changing maladaptive behaviours, decreasing the sense of personal distress and helping the client to adapt better to her/his environment.
Therapeutic Relationship or Alliance is the term used to describe the special relationship between the client and the therapist. This has two components.
• The first component is the contractual nature of the relationship in which two willing individuals enter into a partnership that aims at helping the client overcome his/her problems.
• The second component is the limited duration of the therapy. This alliance lasts until the client is able to deal with his/her problems.
Unconditional positive regard involves the therapist encouraging a high level of trust with the client that enables him/her to confide in the therapist by adopting an accepting, empathetic and genuine attitude towards the client, and conveys through this attitude that he/she is not judging the client and will continue to show the same positive feelings towards the client despite any negativity in attitude or information shared.
Steps involved in formulation of a client’s problem
Clinical formulation refers to formulating the problem of the client in the therapeutic model being used for the treatment. It is an ongoing process. Formulations may require reformulations as clinical insights are gained in the process of therapy.
• Understanding of the problem – The therapist is able to understand the full implications of the distress being experienced by the client.
• Identification of the areas to be targeted for treatment in psychotherapy
• Choice of techniques for treatment – it depends upon the therapeutic system in which the therapist has been trained. Even within this broad domain, the choice of techniques, timing and expectations of outcome of the therapy depend upon the clinical formulation.
Psychodynamic therapy pioneered by Sigmund Freud is the oldest form of psychotherapy, which was modified into analytical psychotherapy by Carl Jung.Psychoanalysis has invented free association and dream interpretation as two important methods for understanding intrapsychic conflicts.
• Free Association – The client is encouraged to freely associate one thought with another, and this free uncensored verbal narrative of the client is a window into the client’s unconscious to which the therapist gains access.
• Dream Interpretation – Commonly used alongside free association, this technique involves asking the client to write down his/her dreams upon waking up. This method looks upon dreams as symbols of unfulfilled desires present in the unconscious. Dreams use symbols because they are indirect expressions and hence would not alert the ego. If these unfulfilled desires are expressed directly,the ego would suppress them and this would lead to anxiety.Transference and interpretation are two means of treating a patient in psychodynamic therapy.
• Transference – The therapist maintains a non-judgmental yet permissive attitude and allows the client to continue with the process of emotional identification, and this is called the process of transference.
In this process, the therapist becomes a substitute for a person that the client harboured negative emotions and associations for in the past, and this stage is called transference neurosis. This stage makes the therapist aware of the nature
of intrapsychic conflicts suffered by the client. Positive transference occurs when the client idolizes or falls in love with the therapist, and negative transference occurs when the client has feelings of hostility, anger and resentment towards the therapist.
The process of transference is met with resistance. Since the process of transference exposes unconscious wishes and conflicts and therefore increases distress levels, the client resists transference. Conscious resistance is present when the client deliberately hides some information. Unconscious resistance is assumed to be present when the client becomes silent during the therapy session, recalls trivial details without recalling the emotional ones, misses appointments, and comes late for therapy sessions.
• Interpretation – It is the fundamental mechanism by which change is affected.Confrontation and Clarification involve the therapist pointing out that a n aspect of the client’s psyche must be faced by the client. Clarification is the process by which the therapist brings a vague or confusing event into sharp focus, which is done by separating and highlighting important details about the event from unimportant ones.
The repeated process of using confrontation, clarification and interpretation is known as working through. This helps the patient understand himself and the source of the problem, and integrate the uncovered material into his ego.The outcome of working through is insight. Insight is a gradual process wherein the unconscious memories are repeatedly integrated into conscious awareness.These unconscious memories are re-experienced in transference and worked through. As this process continues, the client gains and intellectual and emotional understanding, called intellectual insight and emotional insight. Insight is the end point of therapy as the client has gained a new understanding of himself.
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