Therapeutic Approaches

Therapy is not a one-size-fits-all endeavour. The most suitable therapeutic modality for any given client depends on several factors, including the nature of the problem or the developmental work the client wishes to do as well as client characteristics including self-awareness, ego-strength, support network, cognitive functioning, personality type, dominant symptoms, diagnosis, age, personal history, etc. The client’s access to resources such as time and medical funding also plays a role in deciding between relitvely short-term versus medium- to longer-term therapeutic approaches.

Another aspect to keep in mind is that not all clients seek therapy because they have “problems,” are facing difficulties, or are suffering from a mental illness.

Therapy is equally beneficial for people seeking personal growth and development, assistance in achieving specific goals, learning more about themselves, reaching their full potential (i.e., self-actualisation), and finding a greater sense of meaning in life.

This page presents a number of therapeutic modalities I draw from in my work. These however do not represent an exhaustive list of all possible modalities that may be used.

Psychotherapy is a dynamic and rapidly evolving field with new, ground-breaking therapeutic models constantly arising.

Approach

The Law of Least Effort

We often associate psychotherapy with negative concepts such as problems, illness, distress, and something we have to change or eradicate. This is actually getting things the wrong way around. Sure, we would want to reduce or eliminate experiences, conditions, and behaviours that are maladaptive, distressing, or harmful to oneself and/or others with whatever degree of urgency is required.

Consider however for a moment the tale of the Tortoise and the Hare. The expected outcome of the race was clear. Immediately identifiable is Tortoise’s problem of being amongst the slowest of animals. Its entire physical engineering undermines speed. We immediately identify the problem what is lacking in Tortoise. The Hare, on the contrary, is perceived as decidedly superior: innate to his engineering are speed, physical agility, and kinesthetic intelligence. We do not consider Hare as having a problem that needs to be changed or eliminated. But then of course the ironic and wildly unexpected outcome: knowing about Tortoise’s slowness, Hare confidently decides to take a nap mid-race, believing he would still beat Tortoise to the finish line despite the time lost.

The perception of Tortoise as deficient is a metaphor of our perception of this problem- and deficiency-focussed enterprise called “therapy”. We identify ourselves in terms of the problem, the impairment, the thing that needs to be changed or eliminated. We were blind to Tortoise’s strengths and advantages, e.g., determination, discipline, effort, perseverance, and an impressive self-awareness of his realistic limitations as well as advantages. We were so blinded by Hare’s apparent superiority that we never considered potential limitations in other areas, such as his attitude, values, and thinking patterns. Hare certainly had good self-esteem and confidence, but this became maladaptive when it grew to arrogance that blinded him to the strengths that would allow Tortoise his unexpected victory. Hare demonstrated over-confidence, laziness, and lack of commitment to the task of executing a competition of physical speed. His over-confidence led to a lack of effort and a disregard for the rules of the game.

Let’s now consider Tortoise to be a client who enters treatment with the notion that his slowness is an impairment and a problem that needs to be changed or removed. Knowing what we now know about Tortoise’s strengths, would we at all attempt to extinguish the slowness and transform him into an avid sprinter? Of course not! For now we know that his already existing strengths of endurance, commitment, effort, and dutifulness can take him much further toward goal achievement and growth than physical speed and agility ever could. Moreover, as Tortoise’s therapist, I am first and foremost interested in identifying, reinforcing, and capitalising on those strengths. Consequently, the impact and magnitude of the perceived “problem” is reduced.

A “deficiency-perspective” of psychotherapy would have me starting Tortoise’s therapy process with loads of physical training to increase his speed. With enough time, perhaps he could become a somewhat faster mover. But this would be more time- and energy-intensive to begin with, and ultimately less beneficial compared to what could result from focussing on and reinforcing the strengths he already has. The law of least effort states that an organism will typically choose the course of action that requires the least amount of effort or energy. It is also called the law of least action. From an evolutionary perspective, this mechanism promotes survival by allowing organisms to conserve vital energy for those tasks essential to sustain life. Our ancient ancestors’ job of hunting and gathering was an energy-intensive endeavour.

Ancient humans required much more energy to acquire food than we do today. All of this means that we are hardwired to achieve an outcome with the least possible amount of energy and effort invested. That might not initially impress as particularly admirable, but it is pure biology imprinted into our DNA. And our biology becomes “mentalised”, forming psychological representational systems, experiences, and processes.

Let me illustrate this principle with the example of hibernation demonstrated by particular animal species. Animals go into hibernation primarily for one or both of the following reasons: either winter temperatures are so severely low that it threatens the animal’s ability to conserve enough energy needed to maintain a survivable body heat; and/or severe food shortages, especially in winter. The adaptive solution is for the animal’s vital bodily functions to slow down to extreme levels to conserve energy for survival. Most notably, heart rate, breathing rate, metabolic rate, oxygen consumption, and body temperatures drop dramatically. All these mechanisms conserve energy by reducing to the absolute minimum the animal’s use of its limited energy reserves. The slowing of the physiology allows a dramatic reduction in the energy expenditure of the hibernating animal. We can therefore see that the law of least effort ensures the survival of hibernating animal species. Through the law of least action, energy is conserved to its maximum, allowing survival despite desperately reduced internal reserves and external resources. Conversely, this means that the animal’s life would be severely threatened if the law of least effort during hibernation were violated.

As mentioned before, in humans, biological mechanisms are mentalised, forming psycholgical experiences and processes in our psyche. The origins of these mentalised biological processes are primal, instinctive, potentially unconscious and – as such – unregulated. The implication for therapy is that an already resource-depleted client (i.e., a client in hibernation) could at a primitive, instinctual level perceive demands of action and effort as a threat to their self-preservation. My aim consequently is initially to identify, reinforce, and optimise the client’s already-existing strengths, advantages, and resiliencies. This is the cornerstone of the law of least effort. Once the warmer season arrives, the decreased demand on the client’s psychic energy then allows one to explore change in relation to feelings, thought patterns, and/or behaviours that cause distress, illness, or harmful coping mechanisms in the individual. Indeed, sometimes the work of therapy does include attempts at change, but it should not be merely that.

It is important that this approach does not suggest that distressing experiences and states of mind should not come into focus. Most certainly the world, all of humanity, and each individual person faces pain and suffering as an unavoidable part of existence. The outlook in terms of this is to take a “dialectical” approach which allows us to manage the ambivalence stemming from the demand to simultaneously hold seemingly contradicting or paradoxical experiences, thoughts, and feelings. Indeed the identification and exploration of feelings on either side is an inherently significant part of the therapy process. The therapeutic perspective from which one facilitates this process can however vary widely depending on the therapist’s theoretical orientation.

At the end of it all, we each create a building unique in architecture and purpose. While doing so, we may as well continue building castles in the sky.

Dialectical Behaviour Therapy (DBT)

Dialectical behaviour therapy (DBT) is a modified type of cognitive behavioural therapy (CBT) first developed by Marsha Linehan. Its main goals are to teach people how to live in the moment, develop healthy ways to cope with stress, regulate their emotions, and improve their relationships with others.

DBT specifically focuses on providing therapeutic skills in four key areas:

Mindfulness enables individuals to accept and be present in the current moment by noting the fleeting nature of emotions, which diminishes the power of emotions to direct their actions.
DBT also inculcates distress tolerance, the ability to tolerate negative emotion rather than needing to escape from it or acting in ways that make difficult situations worse.
Emotion regulation strategies give individuals the power to manage and change intense emotions that are causing problems in their life.
Last but not least, DBT teaches techniques of interpersonal effectiveness, allowing a person to communicate with others in a way that is assertive, maintains self-respect, and strengthens relationships; a core principle is that learning how to ask directly for what you want diminishes resentment and hurt feelings.

Studies are indicating that DBT is an effective treatment modality as related to:

suicidal behaviour
self-harming behaviour
depression and other mood disorders
borderline personality disorder
substance use disorders
trauma and PTSD
binge-eating disorders
sexual abuse trauma
distress tolerance
emotion regulation

Humanistic Psychotherapy (Person-Centred)

The humanistic approach focuses on self-growth that leads to actualisation. This includes exploring and developing a person’s creativity, freedom, strengths, spirituality, and values. Personal responsibility, freedom of choice, and self-mastery are the essential components of humanistic therapies.

Person-Centred therapy or Rogerian psychotherapy (pioneered by Carl Rogers), requires the authentic personal involvement between both client and therapist. It is a real relationship wherein both view each other as important and the client feels valued for herself rather than for thinking, feeling, or behaving in ways others think she should.

The therapist draws from his own experience to express genuine understanding and empathy for the client’s situation. The message to the client is, “I feel what you’re feeling. I know what you’re going through.” When the client perceives the counsellor’s unconditional acceptance and positive regard, the client feels safe exposing her vulnerability and anxiety.

Person-centred therapy is concerned with the client’s present experience. There is no particular structure to this non-directive approach. The therapeutic relationship itself provides the means for the client to find her own solutions to problems or obstacles that get in the way of fulfilment.

Person-centred therapy bridges the gap between a client’s ideal self and her actual self. Its primary goals are increased self-esteem and greater openness to experience. The objectives may include lower levels of defensiveness and insecurity, less guilt and more self-understanding, more positive and comfortable relationships, and an increased capacity to fully experience and express feelings at the moment they occur.

Existential Psychotherapy (Logotherapy)

Psychiatrist and psychotherapist Viktor Frankl developed logotherapy after surviving Nazi concentration camps in the 1940’s. His experience and theories are detailed in his timelessly iconic book, Man’s Search for Meaning.

Frankl believed that humans are motivated by something called a “will to meaning,” which is the desire to find meaning in life. He argued that life can have meaning even in the most miserable of circumstances and that the motivation for living comes from finding that meaning. This opinion was based on his experiences in the concentration camps and his intent to find meaning through his suffering. In this way, Frankl believed that when we can no longer change a situation, we are called to manage our inner worlds and attitudes instead.

Frankl viewed logotherapy as a way to enhance existing therapies by emphasising the “meaning-dimension” or spiritual dimension of the human psyche. The basic tenets of logotherapy are that:

Human life has meaning,
Human beings long to experience their own sense of life meaning, and
Humans have the potential to experience meaning under any and every circumstance.

The above-mentioned three points are somewhat elaborated upon below:

Freedom of will asserts that humans are free to decide and can take a stance toward both internal and external conditions. In essence, we are free to choose our responses no matter our circumstances.
Will to meaning. As humans, our primary motive is to search for meaning or purpose in our lives. Frankl calls this our will to meaning. We are capable of surpassing pleasure and supporting pain for a meaningful cause.
Meaning in life is based on the idea that meaning is an objective reality rather than merely an illusion or personal perception. Humans have both freedom and responsibility to bring forth their best possible selves by realising the meaning of the moment in every situation.

Frankl left us with valuable propositions on exactly how and where we might be able to find meaning in life. These are outlined below.

Creative Values

Values experienced through what we contribute to life.
Creative contributions allow us to feel meaningfully part of life.
This is not limited to creative works of arts, but can include raising a child, serving one’s community, and any other avenues of contributing to the betterment of others and the world.

Experiential Values

Blessings we receive from life.
Manifested in what is good, beautiful and true.
Results in gratitude and appreciation.
The greatest of these is love.

Attitudinal Values

“Tragic triad”: inevitably we are confronted with guilt, suffering, and death.
The attitudes we have towards life, especially towards inescapable suffering.
Suffering in life is inevitable and we cannot safeguard ourselves against it.
To find meaning in life is thus to find meaning in suffering.
It then follows that If there is a purpose in life at all, there must be a purpose in tragic events.
Suffering does not deprive the person of his freedom to decide how he will deal with his suffering.
In the face of inevitable suffering, what remains is the person’s freedom to determine his responses to it.

Frankl believed that many illnesses or mental health issues are disguised existential angst resulting from people’s struggle with lack of meaning, which he referred to as the “existential vacuum.” Logotherapy addresses lack of meaning directly by helping people uncover meaning and reduce their feelings of angst.

Having a meaning or purpose in life (or engaging in a search for meaning) appears to be connected to our overall health, happiness, and life satisfaction. It also acts as a positive influence on our resilience. Perhaps not surprisingly, there is evidence that meaning in life correlates with better mental health.

This knowledge can be applied in the treatment of issues such as:

Anxiety
Depression
Grief
Pain
Phobias
PTSD
Schizophrenia
Substance abuse
Suicidal ideation

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Brief Dynamic Psychotherapy

Hanna Levenson (2010) describes brief dynamic therapy as “a time-efficient treatment in which the therapist maintains a focus on specific client issues and goals, all within a basic psychodynamic conceptual framework. Many different approaches fit this general definition, but each shares the brief dynamic characteristics of time management, defined focus, circumscribed goals, active therapist participation, rapid assessment, prompt intervention, an awareness of unconscious processes, and techniques that quickly foster a strong alliance with the client”.

Dr. Levenson discusses the approach of brief dynamic therapy in general, but focuses on one example, time-limited dynamic psychotherapy, to give readers a richer understanding of this popular model. Time-limited dynamic psychotherapy is an integrative approach that uses recent developments in attachment theory, interpersonal neurobiology, affective–experiential learning, and systems orientations to help clients with long-standing, dysfunctional ways of relating to others. It provides a specialised method for delineating the client’s cyclical maladaptive interpersonal patterns that can lead to symptoms like depression and anxiety. This approach privileges empathic attunement and awareness of moment-to-moment affective shifts within the client, and transactions between the client and therapist.

Brief dynamic therapy is therefore particularly suited for clients who need to address interpersonal relational difficulties within a reasonably limited timeframe.

Cognitive Behavioural Therapy (CBT)

Cognitive behavioural therapy (CBT) is a form of psychological treatment that has been demonstrated to be effective for a range of problems including depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders, and severe mental illness. Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life. In many studies, CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications.

It is important to emphasise that advances in CBT have been made on the basis of both research and clinical practice. Indeed, CBT is an approach for which there is ample scientific evidence that the methods that have been developed actually produce change. In this manner, CBT differs from many other forms of psychological treatment.

CBT is based on several core principles, including:

Psychological problems are based, in part, on faulty or unhelpful ways of thinking.
Psychological problems are based, in part, on learned patterns of unhelpful behaviour.
People suffering from psychological problems can learn better ways of coping with them, thereby relieving their symptoms and becoming more effective in their lives.

CBT treatment usually involves efforts to change thinking patterns. These strategies might include:

Learning to recognise one’s distortions in thinking that are creating problems, and then to reevaluate them in light of reality.
Gaining a better understanding of the behaviour and motivation of others.
Using problem-solving skills to cope with difficult situations.
Learning to develop a greater sense of confidence in one’s own abilities.

CBT treatment also usually involves efforts to change behavioural patterns. These strategies might include:

Facing one’s fears instead of avoiding them.
Using role playing to prepare for potentially problematic interactions with others.
Learning to calm one’s mind and relax one’s body.

Not all CBT will use all of these strategies. Rather, the psychologist and patient/client work together, in a collaborative fashion, to develop an understanding of the problem and to develop a treatment strategy. CBT places an emphasis on helping individuals learn to be their own therapists. Through exercises in the session as well as “homework” exercises outside of sessions, patients/clients are helped to develop coping skills, whereby they can learn to change their own thinking, problematic emotions, and behaviour.

Source: APA Div. 12 (Society of Clinical Psychology) (verbatim)

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What about Medication?

Psychologists do not prescribe medication. It falls outside our scope of practise because we did not undergo medical training.

Psychopharmacological medication is usually prescribed by a psychiatrist. Psychiatrists are fully trained physicians who – after their initial medical training – went ahead and specialised in psychiatry.

My role as a psychologist is to evaluate the efficacy of psychotherapy and if considered potentially beneficial or necessary, to refer clients to a psychiatrist for evaluation of the need and suitability of including psychopharmacological treatment to the management plan.

The psychiatrist does follow-up sessions with the client to assess the efficacy of the medication prescribed. There is a broad range of pharmacological agents available in all major medication categories, including anti-depressants, anxiolytics, anti-psychotics, etc. Sometimes a client needs to try different medications until the best fit for the client is found. As unique individuals we respond very differently to different psychopharmacological treatments.

Clients also differ in terms of how long they need to use medication. It is extremely important that these medications are used following the guidance of a psychiatrist and to never quit a medication without his/her guidance, as this can have very serious psychological effects.

For various reasons, some clients feel uncomfortable with the idea of using psychiatric medication. The use of psychopharmacological treatment categorically does not mean that a person is weak, has some type of character flaw, or that the essence of one’s character or personality will be changed by such treatment. We would surely not judge negatively a person who suffered multiple fractures in a severe vehicle accident for using pain relief medication. It is illogical to perceive the use of medication for the management of psychological pain and distress any differently. Nonetheless, clients’ feelings about the use of psychiatric medication can be openly discussed to identify a way forward that will be of optimal benefit to the client’s wellbeing.