Psychological Intervention

Psychological interventions are methods of inducing changes in a person's personality, behavior, and feelings. They are also called psychotherapy. Psychotherapy involves intervention in the context of a professional relationship - a relationship sought by the client or concerned others (COs). It might be termed a conversation with a therapeutic purpose. But more broadly, it refers to any intentional application of psychological techniques by a clinician to the end of effecting personality or behavioral change. These interventions go by different names - psychoanalysis, client-centered therapy, behavior therapy, group therapy, and so on. Though each has some unique defining natures, they also share some common features.

All systems of psychotherapy start from the fundamental assumption that human behavior can be changed. The personality of the individual, his capacities for coping (whether adaptive or maladaptive), represents the residuals of a lifetime of learning. Since psychological problems develop through learning, they can be undone through learning and relieving in therapy. That psychology can provide conditions for learning is the faith on which clinicians operate. Ideally, the client shares this faith, which combined with his discontent and his desire for change, is the basic force required for therapeutic improvement.

Wolberg (1977) defined psychotherapy as "a form of treatment for problems of emotional nature in which a trained person deliberately establishes a professional relation with a client with the aim of removing, modifying, or retarding existing symptoms, of mediating disturbed patterns of behavior, and of promoting positive personality and development." Rotter (1971) defined it as "a planned activity of the psychologist, the purpose of which is to accomplish changes in the individual that will make his life adjustment potentially happier and more constructive, or both." A broader definition than the two above is that psychotherapy is a planned emotionally charged, confiding interaction between a trained, socially sanctioned healer and a sufferer. During this interaction, the healer seeks to relieve the sufferer's distress and disability through symbolic communications, primarily words but sometimes bodily activities. The healer may or may not involve the sufferer's relatives and others in the healing rituals. Psychotherapy also often includes helping clients to accept and endure suffering as an inevitable aspect of life that can be used as an opportunity for personal growth.

For a better understanding of the term psychotherapy, some words and phrases need to be explained. The first two are conversation and communication - these imply that psychotherapy usually involves verbal exchanges between the clinician and the client. Thus, a client who cannot verbalize his/her problems or not articulate may not benefit from psychotherapy. However, some forms of bodily movements (for example, behavior therapy) also involve some forms of bodily movements, as in deep muscle relaxation. Psychotherapy is planned or intentional activity directed towards an end/goal. This distinguishes it from everyday conversation, as in advice from friends and others.

Not too long ago, the term psychotherapy was used almost exclusively to refer to a form of psychiatric treatment employed with severely disturbed individuals. The related term counseling referred to the treatment of people with less severe adjustment problems and everyday difficulties related to work, family, school, or marriage or advice given on vocational and educational matters. Counseling, the provision of both advice and psychological support, is the most elemental form of psychotherapy. It can be short-term therapy done to assist a person in dealing with an immediate problem such as marital problems or family planning, substance abuse, and learning difficulties. Or it may be longer-term, more extensive treatment that addresses feelings and attitudes that impair success. Today, the distinction between psychotherapy and counseling is quite blurred, and many mental health professionals use the terms interchangeably. Psychotherapists and counselors often treat the same kinds of problems and use the same set of techniques (Kemp, 1990).

The relationship between the therapist and the client is similar in some respects to all other human and professional relationships. In some regards, it is like that between any expert and his client; in some other ways like that between the teacher and his pupil/student or the pastor and his parishioners; in still other respects, it resembles the interplay between friends, intimates, or relatives. Psychotherapy is a professional relationship involving an expert offering his services to a needful person. It is an intense and intimate relationship in which the client is assured of privacy, confidentiality, and moral neutrality. The goal of the relationship is to advance the client's well-being and relieve his suffering.

There is a divergence of opinions on this issue depending on who you ask. However, research evidence from both meta-analytic and survey studies (Klerman, 1983; Brown, 1987) does indicate that:

1. Results point to the fact that there are some improvements for a majority of clients. This is said to amount to about 80% of clients.
2. All mental health professionals (psychiatrists, clinical psychologists, psychiatric nurses, etc.) rate psychotherapy as effective.
3. Clients who receive psychotherapy alone improve as much as those who receive both psychotherapy and chemotherapy.
4. Longer psychotherapeutic treatment often results in more improvements.

Thus, we need not dwell too much on the issue as the evidence seems to indicate that clients derive some benefits from psychotherapy. The point then is what dysfunctions or disability can psychotherapy ameliorate or cure?

Disorders and changes possible in psychotherapy

Problems	Changeability
Panic disorder	Curable
Specific phobias	Almost curable
Sexual dysfunctions	Marked relief possible
Social phobias	Moderate relief possible
Agoraphobia	Moderate relief possible
Depression	Moderate relief possible
Obsessive-compulsive disorder	Mild/Moderate relief possible
Anger	Mild/Moderate relief possible
Alcoholism	Temporary relief possible
Overweight	Marginally relief possible

We must accept that some problems are difficult to change, whereas other conditions are amenable to change. A review of several researches by Seligman (1993) indicates the following as listed in the table above. Some of the reasons adduced for this difference in the effectiveness of psychotherapy are twofold. First, some disorders are innate or biologically determined. For example, researchers have pointed to the fact that alcoholism and obesity have some inherited components. Second, some strongly held beliefs that are very difficult to disconfirm. For example, it will be very difficult to convince a paranoid individual that others are not out to harm him/her.

As noted earlier, although hundreds of psychotherapeutic techniques (brands) have their own unique features, they also share some common features. The similarities among most of them can be grouped into three:

1. Support Factors: Most, if not all, psychotherapeutic techniques lay the groundwork for change and result in positive relationships, trust, insight, and emotional release. The therapist is a helper and shows sympathetic concern, making continuous efforts to understand and help the client. This is achieved without responding with their own needs and feelings or the demands of social conventions. The therapist must value the client's integrity, avoid questioning inadequacies, and maintain necessary objectivity and detachment. The therapist must be simultaneously compassionate and dispassionate.
2. Learning Factors: Psychotherapy provides clients an opportunity to learn. The learning might take the form of cognitive learning (advice, affective experiencing, and feedback). The learning often leads to behavioral change. The learning that takes place is not intellectual, as when someone acquires new knowledge in an area they were formerly ignorant. For therapeutic change to occur, the learning must be personally meaningful and emotionally important experiences in the favorable conditions of a therapeutic relationship. The client has to experience those emotions they were unable to cope with in the past. The client must come to know their problem better, including the knowledge of its origin. However, this is secondary.
3. Action Factor: Some forms of action/motor activity usually occur in psychotherapy. It may take the form of home assignments/work, role-play, or bodily movements. These often result in mastering new tasks, taking on tasks, practice, and so on.

Because therapeutic change depends on cognitive, experiential, and emotional learning, it necessarily takes time and the client's active participation. Unlike medicine where the patient's problems can be solved with one dose, much arduous and painful work is required if the client has to discover himself. All the therapist can usually do is to provide conditions that will facilitate his therapeutic self-discovery.

A lot of personality variables come into play during the process of psychotherapy and thus influence the outcome of the process. They may be those pertaining to the client or those pertaining to the therapist.

Client Characteristics:

These are variables that clients bring into therapy.

1. Degree of Distress: The degree of the client's distress, that is his/her feelings of Discomfort versus his/her Overt Behaviour. Some clients' Disorders may not show in their Overt Behaviour, making it difficult to Discern the Goal of Therapy.
2. Age: Younger clients tend to benefit more from Therapy. This may be because they are Flexible and Malleable or that Dysfunctions of Older Persons have been Long-lasting and thus Difficult to Change.
3. Motivation: The client must be Highly Motivated to Change in order to Overcome the Length, Frustrations, Outcome, etc. of Therapy.
4. Intelligence: Therapy requires a Reasonable Level of Intelligence for the client to Grasp and Understand the Verbal Exchanges that take place in Therapy.
5. Openness: The client must be Open to New Experiences, have Respect for, and be Optimistic about Therapy. She/He must have some Trust in Therapy.

Therapist Characteristics:

Clinicians often bring a lot of variables into therapeutic processes without sometimes being aware of such.

1. Personality: Researchers have listed a host of personality traits that the effective therapist must possess. However, it is difficult to ascertain which personality variables affect the outcome of therapy more.
2. Rogers Conditions: Rogers (1951) listed empathy, warmth, genuineness, acceptance, interest in people, and commitment to the client as conditions necessary and sufficient for therapeutic change. It must be noted he also says that these are not qualities of the therapeutic relationship and there has been no research evidence in support of these propositions.
3. Sexual Exploitation: The therapist must refrain from sexually exploiting his/her clients. Due to the close affiliation built up over time, it is quite possible for the therapist and client to become sexually intimate. This must be avoided, and professional relationships maintained.
4. Experience: The experience and professional identification of the therapist have been found to affect the outcome of therapy. Of course, other therapists with long years of experience in handling different types of disorders would be more effective than a year-old therapist just starting out in the profession.

Assessment:

This may take or start during the initial contact and/or may be continued during one or more further appointments.

Setting Goals:

Goals are set early in the therapeutic process even though they may be modified as therapy progresses. Once the assessment data has been interpreted and integrated, the client and the therapist must negotiate the goals of treatment. Clients often start therapy with a notion, sharply or not sharply articulated, of what they want and expect from therapy. Therapists must recognize these expectations and help the client to clarify them. Specification of the client's problems and the most effective way to alleviate them is discussed. How therapy proceeds derives from the goals. Consequently, the therapeutic strategies are defined in terms of goals set at the beginning of the therapeutic process.

Therapeutic Contract:

This is a set of mutual obligations and understandings between the client and the therapist. It covers such matters as the goals of therapy, length of therapy, the client's responsibilities, and the general format of therapy. All of this must be openly discussed and freely negotiated. Various aspects of the contract may be modified as therapy progresses.

Implementing Treatment:

At this stage, it is expected that all the above processes have been gone through and that the therapist has determined the best forms of intervention that are necessary based on the goal(s) set. Then the procedures (clinic discussions, homework, assignments, self-monitoring, etc.) involved in the intervention must be carefully described to the client. The essential processes at this phase of the therapeutic process are fourfold:

1. Therapeutic Alliance: Therapy depends on the development of a therapeutic alliance between the client and therapist. It requires the voluntary participation of the client and a readiness to sacrifice the necessary time, effort, and money. It depends on a high level of motivation, both to start and to continue, as there will be inevitable hardships and traits along the way. The client must be willing to communicate feelings and experiences. On his/her own part, the therapist must be willing to remove dissatisfaction and not cause too much pain.
2. Setting Limits: This refers to behavior that occurs during the process of therapy. Clients must be made to understand that verbal or physical abuse is not allowed in therapy. The client may vent angry feelings verbally but remain refrained from verbal or physical assault on the therapist. The therapist must not be judgmental or moralistic. All communications must be directed toward the exploration of the client's experiences and feelings.
3. Flow of Communication: The client talks about his experiences and feelings, wishes and fantasies, problems he is facing at present and memories of the past, anticipated events and plans for the future. He conveys these through words, silences, gestures, etc., some of which are intended and some not. The therapist listens, tries to comprehend the client's meanings, notes themes, repetitions, and omissions. He then comments (reflects back), in ways intended to clarify, extend, or relate (interpret) the client's communication or simplify to stimulate or guide the flow of communication. Thus, the continual flow of conversation is sustained between the two.

In this transaction, the role of the therapist is to (a) reduce inhibitions, (b) suggest topics for discussion, (c) steer the conversation in desired directions, and (d) recognize or clarify or interpret the client's meanings.

Examining Experience:

Overall, the therapeutic dialogue centers on the client's present needs, problems, and life experiences. In the early phase of therapy, much attention is given to the client's symptoms and the problems to capture fully what is troubling him and why he sought therapeutic help. In these early appointments/sessions, the client describes the symptoms, their intensity, maintaining factors, etc., of the problem. Subsequent communications may expand on these to include family, social, and occupation contexts, etc., that should facilitate self-disclosure and discovery.

Termination of Therapy:

This is the final phase of the therapeutic process. The client that came for help must, of course, be released from the contract entered into at the beginning of therapy. In some cases, this final phase is envisaged at the time the goal(s) are set, so it must be discussed with the client all along the process. Termination of therapy may occur in two ways: sudden and gradual. In the sudden termination, the client, for one reason or the other, may stop keeping appointments and/or the therapist, after noting remarkable improvements in the client's conditions when the client demands, terminate therapy. Gradual termination might take a short time (one month) or several months in duration. With this form of termination, one of the following may be possible.

1. Evaluation: All through the process of therapy, the therapist must constantly monitor improvement in the client's presenting problem. He may have to use the assessment techniques earlier employed (recall we said that assessment is an ongoing process). Determine which goal(s) have been met and which need to be tackled, set new goals if need be, and decide on the need to continue or terminate therapy.
2. Booster/Follow-up: Should the therapist decide that the client has improved sufficiently enough or not, he may set some appointments for further contacts between therapist and the client. These further appointments are longer than when therapy was in full swing. For example, instead of being one hour per week, it could be one hour per month, two months, or more as the therapist and the client would agree. At these follow-up sessions, evaluations are carried out, and the process noted. Finally, therapy is terminated after one or several follow-up sessions.

A psychological problem comes to light when someone is distressed - the person himself, his immediate family, or friends or the larger society. As psychologists, we describe criteria for repaired, adequate, and optimal functioning, and we may help people interpret their status by these criteria. Help is sought when the individual or those about him are disturbed by his condition. For a problem to be called "psychological," the primary manifestations (symptoms) should be of psychological functioning (e.g., inability to concentrate, to work effectively, to solve problems) or aberrant needs or behavior (e.g., intense aggressiveness, compulsive acts).

People with Problems

Clinical psychology is concerned with understanding and improving human functioning. Along with other fields of psychology and the behavioral sciences, it shares the task of increasing knowledge about the principles of psychological functioning in "people in general," but its unique concern is with the human problems of a person in particular.

Clinical psychology is one of the mental health professions. It shares responsibility for increasing the well-being of psychologically troubled people. It is dedicated to improving the lots of individuals in distress, using the best knowledge and sharpening the techniques needed for improved intervention in the future, especially through research.

Human Problems within the Purview of Clinical Psychology

What are the problems that concern clinicians? Who defines them as problems, sees them as psychological, and decides that the efforts of a psychological clinician are appropriate?

The social definitions involved in declaring that a problem exists, to be psychological in nature, and to necessitate psychological care differ from place to place and from time to time.

At one time or the other in our lives, we experience inadequacy, helplessness, or anxiety, and we manifest behaviors which to us or others around us are strange and frightening. Thus, the society determines whether such behavior being exhibited by persons needs the police, priests, physicians, lawyers, or other social agents. It is completely determined by personal or social values, laws, and customs. Many human problems which in the past were treated by families or friends, priests, or doctors have now moved into the realm of the psychological clinician. With growing psychological mindedness, the range of human problems viewed as psychological has expanded greatly. Issues formally in the domain of education, criminal justice, and medicine have been reconceived as psychological in nature and are amenable to psychological intervention.

1. Psychoanalysis
2. Behavioural Therapy
3. Experiential Therapies
4. Existential Therapy
5. Gestalt Therapy
6. Cognitive Behaviour Therapy (CBT)
7. Mereson Therapy
8. Family Therapy
9. Marriage Counseling
10. Group Therapy
11. Encounter Group

1. Psychoanalysis

   Developed by Sigmund Freud, psychoanalysis aims at the reconstruction of personality. It involves the relief of symptoms through the systematic use of:

   • Free association
   • Dream analysis (examining both the manifested and the latent content of dreams)
   • Interpretation
   • Analysis of transference and resistance

   This method of therapy typically takes a long time and requires many sessions.

   Process of Psychoanalytic Therapy

   1. Free Association

      The central task of psychoanalysis is to bring out the hidden unconscious wishes and conflicts underlying present symptoms and behavior. Free association is a crucial tool for this, requiring the patient to minimize conscious control and tell everything that comes to mind.

   2. Resistance

      Issues manifest as blocks, periods of silence, deliberate forgetting, avoidance of topics, and opposition to change even when seeking it.

   3. Dream Analysis

      Dreams reveal deep-seated emotional problems, strains, and conflicts of the patient. Both manifest and latent contents of dreams are examined.

   4. Transference

      The core of psychoanalytic therapy where the patient displays strong personal feelings toward the therapist, either positive (admiration, respect, love) or negative (hatred, contempt, anger).

   5. Interpretation

      The fundamental tool in analyzing a patient's production, making the unconscious conscious, and along with free association, is the hallmark of psychoanalytical technique.

2. Behavioural Therapy

   Behavioural therapy focuses on the behavior itself rather than the subjective determinants of behavior. It assumes that emotional disturbances are learned reactions to coping with various stresses. In therapy, the principles of learning and relearning are put into practice. Basic techniques include:

   • Systematic desensitization
   • Implosive therapy/flooding
   • Aversion therapy
   • Token economy (used mostly in an institutionalized setting)
   • Modelling

3. Experiential Therapies

   Developed in the mid-twentieth century, experiential therapies emphasize the relationship with the therapist and the process of activating emotions to help a person create new meanings. Therapists use empathy, the accurate awareness of the client's emotions. Experiential therapists focus on creative and expressive aspects of people, rather than problematic and symptomatic features. Examples include:

   • Client-Centered Therapy
   • Existential Therapy
   • Gestalt Therapy
   • Emotion-Focused Therapy (e.g., Cognitive-Behavioral Therapy (CBT))

   Humanistic Psychotherapy

   Client-Centered Therapy

   Developed by American psychologist, Carl Rogers, Client-Centered Therapy proposes that the key ingredient in therapy is the attitude and style of the therapist rather than a specific technique. It emphasizes the goodness of human nature and assumes the following:

   1. People can be understood from the vantage point of their own perceptions and feelings, major determinants of behavior.
   2. Healthy people are aware of the reasons for their behavior.
   3. Healthy people are innately good and become disturbed only when faulty learning intervenes.
   4. Healthy people are purposeful, goal-directed, and self-directed.
   5. When people are not concerned with the evaluations, demands, and preferences of others, their lives are guided by an innate tendency for self-actualization, fulfilling one's potential as a human being.

   This approach is aligned with humanistic principles in psychotherapy.

4. Existential Therapy

   Therapists emphasizing existential therapy focus on personal growth, similar to humanistic theories. According to the existential viewpoint, true aliveness involves confronting anxieties associated with existential choices. People must take responsibility for themselves even in troubled times.

   The aim of existential therapy is to encourage clients to confront anxieties related to choices about how they live, what they value, and how they relate to others. Therapists support clients in examining what is truly meaningful in life, even if the most important decisions are uncomfortable. Despite the presence of others, the therapy emphasizes that each individual is ultimately alone, responsible for their own existence and capable of redefining themselves at any moment within certain limits.

5. Gestalt Therapy

   Derived from the work of Fritz S. Perls, Gestalt therapy combines humanistic and existential elements. Similar to Rogers, Perls believed in the innate goodness of people, and psychological problems arise from frustration and denial of this inborn virtue. Gestalt therapy aims to help clients understand and accept their needs, desires, and fears, enhancing their awareness of how they block themselves from satisfaction and goal attainment.

   A key assumption is that perceptions are shaped by the needs and goals individuals bring to any situation. Gestalt therapists focus on the present moment in sessions without delving into the past. The therapy emphasizes that the most crucial event in a client's life is what is happening at the moment, discouraging "why" questions, as searching for causes in the past is seen as an attempt to escape responsibility for making choices in the present.

6. Cognitive Behaviour Therapy (CBT)

   All cognitive approaches share the emphasis that how people construe themselves and the world is a major determinant of the kind of people they will be. They believe that individuals have choices in how they construct things and can choose to think differently. Cognitive behaviour therapists focus on private events, thoughts, perceptions, judgments, self-statements, and even tacit (unconscious) assumptions to understand and modify overt and covert disturbed behavior. Cognitive restructuring is a general term for changing a pattern of thought presumed to be causing disturbed emotions or behavior.

   The earliest forms of cognitive behavior therapy include Becks' Cognitive Therapy and Ellis Rational-Emotive Behavior Therapy (REBT).

   a. Becks Cognitive Therapy: Psychiatrist Aaron Beck developed this therapy for depression based on the idea that a depressed mood is caused by distortions in the way people perceive life expectancies. The therapy addresses biases by persuading patients to change their opinions of themselves and the way they interpret life's events. The general goal is to provide patients with experiences that alter their negative schemas, enabling them to have hope rather than despair.

   b. Ellis Rational-Emotional Behavior Therapy (REBT): Albert Ellis developed REBT with the principle thesis that sustained emotional reactions are caused by internal sentences that people repeat to themselves. These sentences reflect irrational beliefs about what is necessary to lead a meaningful life. The aim is to eliminate self-defeating beliefs. Instead of wanting something to be a certain way, feeling disappointed, and then perhaps engaging in some behavior to bring about the desired outcome, the therapy focuses on the irrational demands people impose on themselves and others, such as the "shoulds," "musts," and "oughts to," which, according to Ellis, create emotional distress and behavioral dysfunctions.

   ABC Theory of Disturbance of Ellis:

   A. Events B. Antecedent (Beliefs) C. Consequence

7. Mereson Therapy

   Mereson Therapy is an African approach to psychological treatment developed by Alfres Awaritefe in 1995. Mereson is derived from an African culture of rejecting the negative as unwholesome while accepting the positive. The word "mereson" comes from the Urhobo language in Delta State, meaning "I reject it."

   The traditional core on which Mereson Therapy is based is "what one says of himself is what happens to him." Man is a striving creature with the ultimate goal of enablement. Striving takes place at three levels: thought, words, and deed. Man is endowed with psychological instruments for striving, including perceptive capacity, appraisal mechanism, and operational facilities. In his striving, man stands at crossroads, making choices at every turn.

   Psychological difficulties arise due to distortions in the appraisal mechanism, making inappropriate choices, or resignation in the face of difficulties. However, man is not helpless; he is endowed with the potential for change. The therapist awakens this realization, enabling the patient to mobilize resources, disassociate from undesirable situations, and become constructive.

8. Family Therapy

   Therapy becomes necessary in family therapy because there is pathology in the communication of family members. The goal of family therapy is mainly to discover how the presenting problem is related to the network of relations in the family and in what ways family members might participate.

9. Marriage Counseling

   Here, the focus is on the relationship between husband and wife and issues related to children.

10. Group Therapy

    Developed during the World War II period, group therapy involves members who complement each other, each contributing in areas where they excel.

11. Encounter Group

    Considered as group therapy for "normals," encounter groups focus on methods to enhance human relations skills and sensitivity training. Concepts such as feedback, interpersonal communication, interpersonal perception, and conscious attention to group process are stressed. The aim is to bring about more effective personal functioning, leadership, or organizational development, not merely personal improvement.