Unit 2 mental health & mental illness

WORLD HEALTH ORGANIZATION defines HEALTH “ is a state of

complete physical , mental and social well – being & not merely the absence of
disease or infirmity ”. According to WHO, Mental Health is a state of well –
being in which the individual realizes his or her own abilities , can cope with
normal stresses of life , can work productively and fruitfully , & is able to make a
contribution to his her community . Mental health is fluid, which means that it
changes throughout our lives and under changing circumstances. It is influenced by
a range of factors, including our life experiences and the social and economic
conditions that shape our lives: the social determinants of health. The good news is
that all mental illnesses can be treated There are multiple associations between
mental health and chronic physical conditions that significantly impact people’s
quality of life, put additional demands on healthcare and other publicly funded
services, and generate consequences to society. Understanding the links between
mind and body is the first step in developing strategies to reduce the incidence of
co-existing conditions and support those already living with mental health
challenges and chronic physical condition

Mental health is more than the absence of a mental health condition. It is a

positive sense of well-being or the capacity to enjoy life and deal with the
challenges we face Mental health also include :

• Subjective well being .

• Perceived self – efficacy
• Autonomy
• Competence
• Intergenerational dependence
• Recognition of the ability to realize one’s intellectual and emotional
potential
• Mental Health refers to the maintenance of successful mental
activity.This includes maintaining productive daily activities and
maintaining fulfilling relationships with others.
The World Federation of Mental Health has come out with a three point
definition of mental health based on the following three questions?

1. Do u feel good about yourself.?

 2. Do u feel comfortable with other people?

3. Are you able to meet life’s demand?

Mental health impacts every one of us ,just like physical health, mental health is
not fixed .Mental health exists on a continuum or range : from positive , healthy
functioning at one end through to severe symptoms of mental health conditions at
the other . A person’s mental health moves back and forth along this range during
their lifetime, in response to different stressors & circumstances. The two-
continuum model helps us understand this. At one end of the continuum , people
are well ; showing resilience & high levels of well being .At the other end people
may start to have difficulty coping and symptoms may increase in severity &
frequency or may be at risk of self harm or suicide .

One end
other end

• Positive , healthy severe impact

on every day
Functioning
functioning

Characteristics of Mentally Healthy Person

1. He knows himself well about his strength & weakness.

2. He has an adequate ability to make adjustment in the changed
circumstances & situations.
3. He is emotionally mature & stable as he is able to express his
emotions in a desirable way & exercise proper control over
them .
4. He is socially adjustable as he possesses an adequate ability to
get along well with himself and others .
 5. His intellectual powers are adequately developed . he is able to
think independently & to take proper decision at the proper
time .
6. He always lives in a world of reality . rather than that of
imagination & fantasy
7. He possess enough courage & power of tolerance for facing
failures in his life
8. He leads a well – balanced life of work , rest & recreation .

Mental health is not static

• It is important to remember that mental health and mental illness are not
static; they change over time depending on many factors. Some of the
factors that influence mental health include: levels of personal and
workplace stress; lifestyle and health behaviours; exposure to trauma; and
genetics.

Connection of mental and physical health

Mental health plays a major role in person’s ability to maintain good

physical health .Mental illnesses such as , anxiety and depression affect
people in health promoting behaviours .In turn, problems with physical
health , such as chronic diseases can have a serious impact on mental health
and decrease a person’s ability to participate in treatment & recovery .

Factors Affecting Mental Health

1. HEREDITARY FACTORS

• Heredity-is the passing of traits from parents to offspring. It shapes one’s

personality and behaviour and make people different.Traits of the parents
and ancestors are transmitted to the children through their genes. Intelligence
and feeblemindedness are inherited.

2. PHYSICAL FACTOR
• A healthy body makes a healthy mind. Unhealthy conditions make life
abnormal. A physical condition of an individual has direct effect on his or
her mental health.

3. SOCIO-CULTURAL FACTOR
 • Child develop attitudes & behavioral patterns from past experiences .Home
being the first environment of the children influences their behavior and
attitude. The community in which an individual belongs may contribute to
the development of his/her mental health .School & religious institutions
may also help in molding child’s personality.

BIOPSYCHOSOCIAL MODEL

The Biopsychosocial model was first conceptualized by George Engel in

1977was regarded as one of the most important development in medicine &
psychiatry . According to him , health is best understood in terms of a
combination of biological , psychological & social factors , all play a
significant role in human functioning in the context of disease or
illness .Biopsychosocial factors influence the prevention , causes ,
presentation, management & out come of the disease . Each of these factors
continuously interacts with the others and together they constitute the unique
state we call illness .The fundamental assumption is that health & illness are
consequences of the interplay of biological , psychological & social factors .
It maintains these are all important determinants of health & illness

 Biological factors such as genetics , disease , injury, harmones ,

diet , drugs , brain chemistry , brain damage, anatomy , etc
 Social factors such as life traumas , upbringing , poverty ,
relationship , stresses , early life experiences , social support ,
education ,race , gender, socio – economic status , ethnicity ,
culture etc
 Psychological factors such as beliefs , emotions , resilience , coping
skills, social skills , self esteem, personality , learning ,self esteem ,
self- efficacy etc
MENTAL HEALTH CARE- PAST & PRESENT

• During the Stone Age, a person with mental disorder was believed to be
possessed by evil spirits that lived in the mind. Boring holes in the skulls of
the mentally ill person would release the evil spirits that dwelled in the
mind, thereby curing the illness.

• Middle Ages- the mentally ill person possessed by the devil was believed to
have supernatural powers to harm others. The remedy was to burn the
 affected person18th Century-Mental illness was considered a shame in the
family. Mentally ill persons were put in jail as a solution to the problem. The
ill persons were chained and hidden from public view.

• Before the beginning of the 19th century, new movements in England and
France began. The chains of mentally ill person were broken. In 1812, an
American social reformer named Dr.Benjamin Rush advocated humane
treatment for the mentally ill persons. His works on mental disorder opened
another field in medicine called Psychiatry, the study and treatment of
mental diseases. Dorothea Dix, a young American school teacher, founded
the first public hospitals for mentally ill persons in 1840’s.

• In the mid-19th century, William Sweetser was the first to coin the term
"mental hygiene", which can be seen as the precursor to contemporary
approaches to work on promoting positive mental health. Isaac Ray, one of
the founders and the fourth president of the American Psychiatric
Association, further defined mental hygiene as "the art of preserving the
mind against all incidents and influences calculated to deteriorate its
qualities, impair its energies, or derange its movements."

• At the beginning of the 20th century, Clifford Beers founded "Mental Health
America – National Committee for Mental Hygiene", after publication of his
accounts from lived experience in lunatic asylums, A Mind That Found
Itself, in 1908 and opened the first outpatient mental health clinic in the
United States.

Today, mentally ill persons receive full humane treatment in all mental hospitals
with funding from government and Non-government agencies

Mental Health care- past & present

Mental Health Care in India

• The Government of India has launched the National Mental Health

Programme (NMHP) in 1982, with the following objectives:

• To ensure the availability and accessibility of minimum mental healthcare

for all in the foreseeable future, particularly to the most vulnerable and
underprivileged sections of the population;
• To encourage the application of mental health knowledge in general
healthcare and in social development; and

• To promote community participation in the mental health service

development and to stimulate efforts towards self-help in the community

• The District Mental Health Program (DMHP) was launched under NMHP in
the year 1996 (in IX Five Year Plan). The DMHP was based on ‘Bellary
Model’ with the following components:

1. Early detection & treatment.

2. Training: imparting short term training to general physicians for diagnosis

and treatment of common mental illnesses with limited number of drugs
under guidance of specialist. The Health workers are being trained in
identifying mentally ill persons.

3. IEC: Public awareness generation.

4. Monitoring: the purpose is for simple Record Keeping.

• In February, 1996, the DHMP was launched in 1996-97 in four districts,

one each in Andhra Pradesh, Assam, Rajasthan and Tamil Nadu with a
grant assistant of Rs 225 lakhs each.

Aims & Objectives of NMHP

• To take (outreach) Mental Health Services to remote village along with other
health Services.

• To delegate – assign different tasks – responsibilities in Mental Health

Services properly.

• To take Mental Health an indispensable component of General Health

Services.

• To all these schemes with other Community/integrate Social development

schemes.

• To enlist people’s participation in Mental Health Services.

 Mental Health Act 1987 from ****** slide share

Revisions made from the Mental Health Act 1987

 The mental Health Care Act 2017 aims at discriminating the attempt to
commit suicide by seeking to ensure that the individuals who have attempted
suicide are offered opportunities for rehabilitation from govt as opposed to
being tried or punished for the attempt given that they have the appropriate
knowledge to do so .
 The Act seeks to fulfill India’s international obligation pursuant to the
convention on Rights of Persons with Disabilities and its optional protocol .
 It looks to empower persons suffering from mental illness, thus marking a
departure from MENTAL HEALTH ACT, 1987. The 20117 Act recognizes
the agency of people with mental illness, allowing them to make decisions
regarding their health , given that they have the appropriate knowledge to do
so .
 The Mental Health Care Act 2017 , includes provisions for the registration
of mental health related institutions and for the regulation of the sector .
These measures include the necessity of setting up mental health
establishments across the country to ensure that no person with mental
illness will have to travel far for treatment , as well as the creation of a
mental health review board which will act as a regulatory body .
 The Act has restricted the usage of Electroconvulsive therapy ( ECT) to be
used only in cases of emergency , and along with muscle relaxants and
anesthesia .Further , ECT has traditionally been prohibited to be used as
viable therapy for minors .
 The responsibilities of other agencies such as the police with respect to
people with mental illness has been outlined in the 2017 Act .
 The mental Health Care Act 2017 has additionally vouched to tackle stigma
of mental illness , and has outlined some measures on how to achieve the
same .
Concept of Mental Illness

• Mental illness is a clinically diagnosable condition that significantly

interferes with an individual’s cognitive, emotional or social abilities. It is a
health condition which involves changes in emotion, thinking , behavior or
combination of all the three. Mental illnesses are associated with distress and
problems in socio – occupational impairment .Mental health conditions are
treatable and improvement is possible .It also warrants medical attention
 when it is affecting the functionality of an individuality of an
individual .Some mental illnesses which are experienced by a person e.g.
depressed mood but does not interfere with the daily functioning of the
person.

• The diagnosis of mental illness is generally made according to the

classification systems of the Diagnostic and Statistical Manual of Mental
Disorders (DSM; American Psychiatric Association, 2012) or the
International Classification of Diseases (ICD; World Health Organization
(WHO), 2013a).

• Mental illness affects men, women and children of all ages, nationalities and
socio-economic backgrounds, and affects the lives of many people in our
community, their families and friends. Mental illness is a recognized,
medically diagnosable illness that results in the significant impairment of an
individual's cognitive, affective or relational abilities.

• Mental disorders result from biological, developmental and/or psychosocial

factors and can be managed using approaches comparable to those applied to
physical disease (i.e., prevention, diagnosis, treatment and rehabilitation).

• Mental illness can occur when the brain(or part of the brain) is not working
well or is working in the wrong way. When the brain is not working
properly, one or more of its 6 functions will be disrupted
Symptoms can include
 When these symptoms significantly disrupt a person’s life, we say that the
person has a mental disorder or a mental illness

• Common and well researched mental illnesses by category includeMood

disorders (affective disorders): Depression, mania and bipolar

• Anxiety disorders: Generalized anxiety disorder, post-traumatic stress

disorder, obsessive-compulsive disorder, panic disorder

• Psychotic disorders: schizophrenia

• Concurrent disorders: addictions and substance abuse

• Personality disorders: antisocial personality disorder, obsessive-compulsive

personality disorder

Types of mental illnesses

• There are many different types of mental illnesses, just as there are many
types of physical illness. Some of the defining characteristics of a mental
illness are:

• that it is a recognized, medically diagnosable illness;

• that it can cause significant cognitive, affective, or relational impairment;

• that it results from biological, developmental and/or psychosocial factors;

• that it can be managed using physical disease approaches (i.e. prevention,

diagnosis, treatment and rehabilitation).

Classifying the Types of Mental Illnesses

• The definitions and classifications of the various type of mental illnesses

have undergone a number of changes.

• Currently there are two accepted systems of classifications of mental health

disorders - one is done by ICD-10 Chapter V: Mental and behavioral
disorders. This manual has been published by the International Classification
of Diseases, WHO since 1949.
• The other is the Diagnostic and Statistical Manual of Mental Disorders
produced by the American Psychiatric Association (APA). This manual has
been in publication since 1952 .

• Both these syndrome-based classifications, list a range of mental health

conditions for example the DSM IV lists around 300 of mental disorders.

Treatment of Mental Illness

• Mental illness, like many chronic illnesses, requires ongoing treatment.

• Medication.

• Psychotherapy.

• Group therapy.

• Day treatment or partial hospital treatment.

• Specific therapies, such as cognitive-behavior therapy and behavior

modification.

Other treatments available include

• Alternative therapies, such as water therapy, massage, and biofeedback.

• Creative therapies, such as art therapy, music therapy, or play therapy.

• Hypnotherapy.

• Electroconvulsive therapy (ECT).

• Vagus nerve stimulation (VNS).

• Transcranial magnetic stimulation (TMS) is a newer therapy.

Mental Health Care is very important . The ultimate purpose of health

interventions is to enhance quality of life rather than simply prolong
life .Quality of life has been assessed in many psychiatric disorders and
serial quality of life assessment now forms an essential part of research
protocols in therapeutic trials .QOL issues in relation mental health care is
especial outcome , especially relevant with regard to
  Baseline assessment of severity of the disease condition.
 Part of evaluation of treatment outcome .
 Identification of high risk population.
 Setting goals for psycho social therapies and rehabilitation.
 Health education
 Prevention and policy making.

Perspective of Mental Health & Illness Psychodynamic Perspective

The central assumption of the psychoanalytic theory that Sigmund Freud

developed was that psychopathology resulted from unconscious conflicts in the
individual. More specifically, freud believed that the various forms of
psychopathology resulted from the presence of strong drives or id instincts, which
set the stage for the development of unconscious conflicts linked to a particular
psychosocial stage . The interplay of these forces is referred to as the
psychodynamics of the personality .Theorists who follow freud’s ideas are
therefore referred to as the psychodynamic theorists .
Th e Psychodynamic App roach to Psychopathology
The Four Psychologies of Psychoanalysis and Beyond
Psychoanalysis encompasses a broad field with a rich historical tradition, and it
has commonly been said that psychoanalysis provides the most comprehensive
approach to human development. However, psychoanalysis is not one unified
approach: Just as in other strands of science, there are different theoretical and
conceptual threads within the larger rubric of “psychoanalysis.” There have been
major shifts over time in psychodynamic approaches. In this context, Pine (1988)
and others have referred to the “four psychologies of psychoanalysis,”
encompassing (1) the traditional Freudian approach, (2) ego psychology, (3) object
relations/
attachment theory, and (4) self psychology .
Each of these approaches is rooted in the application of psychoanalytic ideas to
different patients and problems. Historically, the different models have evolved
through attempts to explain why and how individuals develop vulnerabilities for
psychopathology in the course of their psychological development. The earliest
models largely derived from clinical experience, with each model focusing on
particular clinical
problems, developmental issues, or phases, and often determined by individual
analysts’ own interests, their setting, and the nature of their patient group or even
specific patients.
The Freudian drive approach essentially emerged out of the study of patients
perceived to be struggling with sexual and aggressive drives. It proposed that
psychopathology is related to failures of the child’s mental apparatus to deal
satisfactorily with the pressures inherent in a maturationally predetermined
sequence of drive states, leading to fixation, and subsequent regression to these
fixation points later in life when the individual is confronted with environmental
adversity, intrapsychic conflicts, or a combination of both .In an effort to redress
the balance of drive theory’s emphasis on sexual and aggressive drives, ego
psychology emerged, with its focus on the child’s adaptive capacities, and
particularly the capacity of the ego to adapt to changing external and internal
demands . Anna Freud developed a more comprehensive developmental theory,
emphasizing the notion of different developmental lines, which continues to be a
central tenet of developmental psychopathology . Additionally, within this focus
on adaptive ego capacities, Erik Erikson (1950) formulated the still influential
epigenetic theory of human development, which places emphasis on different
developmental tasks throughout the life cycle. A rich body of developmental
research continues to be based on Erikson’s formulations.Object relations and
attachment theory developed out of dissatisfaction with the largely “intrapsychic”
focus of both the drive approach and ego psychology and these theories’ inability
to explain the distortions in self and interpersonal relationships that are typically
observed in individuals with psychotic and borderline features. Object relations
theory is based on the central assumptions that (1) relationships are primary to
drive satisfaction, rather than secondary, as is assumed in traditional drive and ego
psychology, and (2) development fundamentally takes place within an
interpersonal matrix, with attachment/interpersonal processes playing a key role in
determining development, rather than a preprogrammed maturational process as is
assumed in drive and ego psychology
Basic Assumptions of Psychodynamic Approaches
 The Developmental Approach within Psychoanalysis Psychoanalytic
theories are fundamentally developmental. They share a distinct emphasis on
the formative role of early life experiences and later psychic structures
Foundations of Contemporary Psychodynamic Approaches and behavior.
Psychoanalytic theories are also inherently developmental in their emphasis
on a gradual unfolding of the mind and mental capacities, with there being
different ways of understanding and knowing the world at different stages of
development. Indeed, psychoanalysts were among the first to offer clearly
explicated stage theories of development . From the beginnings of
psychoanalysis, psychoanalytic clinicians, starting with Sigmund Freud,
Karl Abraham, and Melanie Klein, to name just a few, were struck by the
critical importance of early developmental disruptions to understanding their
patients’ complaints. They conceptualized different forms of
psychopathology as dynamic conflict–defense constellations, rooted in early
 adverse experiences and disruptions and/or impairments of early capacities
and stages of development. Unsurprisingly, the theories these early
clinicians built up were thus fundamentally developmental in nature .Broad-
ranging research findings have further confirmed and extended the early
psychoanalytic emphasis on the formative nature of early experiences .
Findings concerning the central importance of early attachment experiences
in setting patterns and prototypes for later expectations, attitudes, and
feelings with regard to the self and others (Main, Kaplan, & Cassidy, 1985),
as well as expectations about one’s capacity to cope with conflict, stress, and
adversity (Gunnar &Quevedo, 2007), further support psychoanalytic
thinking about the importance of early developmental factors.
psychoanalytic approaches aim to explain both normal and disrupted
development, with a focus on factors explaining developmental disruptions
(Fonagy & Target, 2003). Psychoanalytic developmental researchers have
therefore played a key role in the field of developmental
psychopathology,that is, the study of the development of psychological
disorders
 Unconscious Motivation and Intentionality
Psychoanalytic approaches focus on the importance of unconscious motivation and
intentionality, consistent with contemporary theoretical models in the
neurosciences , cognitive science, and social psychology. Whereas historically this
was a unique position, there is now increasing consensus across several fields that
factors influencing psychological development often exert their influence outside
of conscious awareness .Moreover, there is also consensus that motivational
factors may conflict with each other, and thus that both normal and pathological
psychological functioning involve conflict—which is, of course, a central tenet of
psychoanalytic approaches. Specifically, the coexistence of processing units from
different developmental stages inevitably leads to conflict between these units, and
psychological functioning thus involves the adaptive resolution of these conflicts,
referred to as compromise formations in psychoanalysis and constraint satisfaction
in psychological forces that are largely outside of the awareness of the individual
play a
key role in achieving such a balance
 The Ubiquity of Transference
Key to psychoanalytic thinking is the notion that social interactions in any context,
but especially in the therapeutic setting, are filtered through internalized schemas
of past relationships, specifically, early caring relationships . Largely if not
primarily unconsciously,these feelings, desires, and expectations regarding earlier
objects are transferred to new relationships, and they are especially important in
understanding both
content and process in the psychoanalytic therapeutic context .Much has been
written about techniques for “working in the transference” and the ways in which
both positive and negative transferences may impede (or at times, facilitate)
therapeutic change. The idea of transference is also closely related to more
contemporary notions from attachment theory about internal working models.
Studies in this area similarly suggest that transference is primarily unconscious,
and that early attachment templates/schemas impact reactions to relationships in
adulthood as well as in other key developmental period .
 A Person-Oriented Perspective
Psychoanalytic approaches typically consider the whole person. Rather than
focusing on the developmental pathways implicated in a particular disorder, or one
symptom, behavior, or personality feature, this person-centered perspective
emphasizes the role of multifinality and equifinality in explaining different
pathways of individuals. Equifinality proposes that there are many possible
pathways toward one specific outcome, rather than assuming that there is a single
pathway for each mental disorder or developmental outcome. Multifinality, in
contrast, implies that a given factor may result in a variety of outcomes, depending
on the presence of other factors. This view thus involves a shift away from disease-
and variable-oriented strategies toward person-oriented research and treatment
strategies. This emphasis is at the core of psychoanalytic developmental theory in
clinical practice, in which the focus is always on the person and his or her
developmental history rather than solely on a particular symptom, disorder, or
developmental outcome . Indeed, psychoanalysis is strongly rooted in an individual
epistemology that emphasizes the importance of specialized knowledge from the
individual and individual meaning-making . Furthermore, multifinality
characterizes the psychoanalytic approach to psychopathology in the implications
for how “disorders” are defined more by an understanding of how an individual’s
presentation is serving adaptive and maladaptive functions, how mechanisms for
these “disorders” are understood in terms of the individual’s history and current
circumstances, and how treatments are oriented toward understanding the role the
“disorder” serves for the individual and how the maladaptive aspects of the
“disorder” may be mitigated.
 Focus on the Inner World and Psychological Causality
Psychoanalytic approaches are characterized by a focus on the inner psychological
world and psychological causality across the lifespan. Psychological development
can be seen as involving a move toward increasing complexity, differentiation, and
integration of feelings, thoughts, and representations of self and others. These
range from the most primitive undifferentiated feelings, thoughts, and fantasies of
the infant to more elaborated, differentiated, and integrated representations of self
and others, or internal working models, hopes, desires, fantasies, dreams, and
fears . Although early psychoanalytic developmental models sometimes attributed
improbable cognitive abilities to infants, their intuition has been shown to be
correct in that current research has amply demonstrated the essentially social
nature of human infants and that the human capacity for social cognition is key to
understanding the confluence of social and biological factors in determining both
normal and disrupted development . These views open up interesting perspectives
for both research and intervention at a time when biological reductionism may
again be on the rise.
 Continuity between Normal and Disrupted Personality Development
The growing evidence for dimensional approaches to psychopathology parallels
the emphasis in psychoanalytic approaches on the essential continuity between
normality and pathology. As noted earlier, from the psychodynamic
perspective ,both normal and disrupted psychological development involve
attempts to find a dynamic equilibrium between the impact (psychological and
biological) of past experiences and current needs in the context of an individual’s
environment .Given the ubiquity of conflict in human development and the
inevitably imperfect resolution of life’s important developmental tasks, human
beings are fundamentally vulnerable to developing psychological problems,
especially when faced with adversity that may trigger latent vulnerabilities and/or
challenge coping strategies that were previously adaptive but have outlived their
usefulness. These views have increasingly been adopted by other theoretical
frameworks, not least by cognitive-behavioral approaches such as schema therapy
(Beck, 2009; Luyten et al., 2013; Young, 1999).

 The root of the abnormality is the effect of repression of unresolved

conflicts between unconscious desires .The behaviour is motivated by
unconscious desires .A key concept in Psychodynamic perspective is the
unconscious and asserts that underlying unconscious or repressed conflicts
are responsible for conflicts, disruptions, and disturbances in behavior and
personality. Repression pushes distressing events into unconscious.
Unconscious is a vast reservoir of fears , unacceptable sexual desires,,
violent motives , irrational wishes , immoral urges , selfish needs,
shameful experiences, & traumatic experiences .
• According to Freud we develop through a no of psychosexual stages in
childhood . if we fail to pass through a stage then we become fixated and
this can cause abnormal adult behaviour. Fixation at a particular
psychosexual stage ,both frustration and overindulgence may lead to fixation
at a particular psychosexual stage . fixation at oral stage leads to oral
activities eg dependency , smoking , aggression .fixation at anal stage leads
to obsessiveness, tidiness , generiosity .fixation at phallic stage leads to
 vanity , self obsession , sexual anxiety , inadequacy , inferiority etc . In
freud’s theory of psychosexual stages, failure to resolve one of the stages
may lead to fixation at that stage .
• Trauma in childhood may be repressed (pushed into unconscious ) in order
to protect conscious mind .Deprivation in the childhood can lead to
personality changes and disorder in adulthood. Our manners and feelings as
adults including psychological problems are rooted in our childhood
experiences .The relationship between child and parents is a crucial
determinant of mental health.

• The key assumption of the psychodynamic approach is that all human

behaviour can be explained in terms of inner conflicts of the mind .
• Mental disorder is caused by unconscious motivations . If these unconscious
motivations clash with our conscious wants and needs , then we have a
problem . Either these unconscious motivations will find a ( possibly
dangerous or unpleasant ) outlet , or keeping them suppressed will become a
problem in itself . Actions are believed to be motivated by emotions and
thoughts. Therefore, to understand and change behavior, a person needs to
develop awareness and insight into his or her thoughts and emotions.

• Psychodynamic perspective is based on Sigmund Freud’s psychoanalytic

theory. The core assumption of this approach is that the roots of mental
disorders are psychological. They lie in the unconscious mind and are the
result of the failure of the defence mechanism to protect the self (or ego)
from anxiety. The ego mediated between the Id and superego , coping with
conflicting demands . Conflicts cause anxiety , so the ego has multiple
defences against these conflicts .These ego defences are unconscious and if
over – used can add to the problem rather than solving it .

• All behaviour has a reason generally unconscious, even slips of the tongue.
As a result all behaviour is determined .

• The psychoanalytic process involves bringing to the surface repressed

memories and feelings by means of a scrupulous unraveling of hidden
meanings of verbalized material and of the unwitting ways in which the
patient wards ongoing underlying conflicts through defensive forgetting and
repetition of the past.
• The overall process of analysis is one in which unconscious neurotic
conflicts are recovered from memory and verbally expressed, re experienced
in the transference, reconstructed by the analyst, and, ultimately, resolved
through understanding. Freud referred to these processes as recollection,
repetition, and working through, which make up the totality of
remembering, reliving, and gaining insight. Recollection entails the
extension of memory back to early childhood events, a time in the distant
past when the core of neurosis was formed. The actual reconstruction of
these events comes through reminiscence, associations, and autobiographical
linking of developmental events. Repetition involves
more than mere mental recall; it is an emotional replay of former
interactions with significant individuals in the patient’s life. The replay
occurs within the special context of the analyst as projected parent, a
fantasized object from the patient’s past with whom the latter unwittingly
reproduces forgotten, unresolved feelings and experiences from childhood.
Finally, working through is both an selective and cognitive integration of
previously repressed memories that have been brought into consciousness
and through which the patient is gradually set free (cured of neurosis
• Major Approach and Techniques
Structurally, psychoanalysis usually refers to individual (dyadic) treatment
that is frequent (four or five times per week) and long term (several years).
All three features take their precedent from Freud himself.
The dyadic arrangement is a direct function of the Freudian theory of
neurosis as an intrapsychic phenomenon, which takes place within the
person as instinctual impulses continually seek discharge. Because dynamic
conflicts must be internally resolved if structural personality reorganization
is to take place, the individual’s memory and perceptions of the repressed
past are pivotal. Freud initially saw patients 6 days a week for 1 hour each
day, a routine now reduced to four or five sessions per week of the classic
50-minute hour, which leaves time for the analyst to take notes and organize
relevant thoughts before the next patient. Psychoanalytic Setting. As with
other forms of psychotherapy psychoanalysis takes place in a professional
setting, apart from the realities of everyday life, in which the patient is
offered a temporary sanctuary in which to ease psychic pain and reveal
intimate thoughts to an accepting expert. The psychoanalytic environment is
designed to promote
relaxation and regression. The setting is usually spartan and sensorially
neutral, and external stimuli are minimized.
USE OF THE COUCH. The couch has several clinical advantages that are
both real and symbolic: (1) the reclining position is relaxing because it is
associated with sleep and so eases the patient’s conscious control of
thoughts; (2) it minimizes the intrusive influence of the analyst, thus curbing
unnecessary cues; (3) it permits the analyst to make observations of the
patient without interruption; and (4) it holds symbolic value for both parties,
a tangible reminder of the Freudian legacy that gives credibility to the
analyst’s professional identity, allegiance, and expertise. The reclining
position of the patient with analyst nearby can also generate threat and
discomfort, however, as it recalls anxieties derived from the earlier parent–
child configuration that it physically resembles. It may also have personal
meanings—for some, a portent of dangerous impulses or of submission to an
authority figure; for others, a relief from confrontation by the analyst (e.g.,
fear of use of the couch and overeagerness to lie down may reflect resistance
and, thus, need to be analyzed).Although the use of the couch is requisite to
analytical technique, it is not applied automatically; it is introduced
gradually and can be suspended whenever additional regression is
unnecessary or counter-therapeutic.
FUNDAMENTAL RULE. The fundamental rule of free association
requires patients to tell the analyst everything that comes into their heads—
however disagreeable, unimportant, or nonsensical—and to let themselves
go as they would in a conversation that leads from “cabbages to kings.” It
differs decidedly from ordinary conversation—instead of connecting
personal remarks with a rational thread, the patient is asked to reveal those
very thoughts and events that are objectionable precisely because of being
averse to doing so.This directive represents an ideal because free association
does not arise freely but is guided and inhibited by a variety of conscious
and unconscious forces. The analyst must not only encourage free
association through the physical setting and a nonjudgmental attitude
toward the patient’s verbalizations, but also examine those very instances
when the flow of associations is diminished or comes to a halt—they are as
important analytically as the content of the associations. The analyst should
also be alert to how individual patients use or misuse the fundamental rule.
Aside from its primary purpose of eliciting recall of deeply hidden early
memories, the fundamental rule reflects the analytical priority placed on
verbalization, which translates the patient’s thoughts into words so they are
not channeled physically or behaviorally. As a direct concomitant of the
fundamental rule, which prohibits action in favor of verbal expression,
patients are expected to postpone making major alterations in their lives,
such as marrying or changing careers, until they discuss and analyze them
within the context of treatment.
PSYCHOANALYTIC PSYCHOTHERAPY
 • Psychoanalytic psychotherapy, which is based on fundamental dynamic
formulations and techniques that derive from psychoanalysis, is designed to
broaden its scope .Psychoanalytic psychotherapy, in its narrowest sense, is
the use of insight-oriented methods only. As generically applied today to an
ever-larger clinical spectrum, it incorporates a blend of uncovering and
suppressive measures. The strategies of psychoanalytic psychotherapy
currently range from expressive (insight oriented,
uncovering, evocative, or interpretive) techniques to supportive (relationship
oriented, suggestive, suppressive, or repressive) techniques.
The duration of psychoanalytic psychotherapy is generally shorter and
more variable than in psychoanalysis. Treatment may be brief, even with an
initially agreed-upon or fixed time limit, or may extend to a less definite number of
months or years.

Expressive Psychotherapy

Diagnostically, psychoanalytic psychotherapy in its expressive mode is

suited to a range of psychopathology with mild to moderate ego weakening,
including neurotic conflicts, symptom complexes, reactive conditions, and
the
whole realm of non psychotic character disorders, including those disorders
of the self that are among the more transient and less profound on the
severity-of-illness spectrum, such as narcissistic behavior disorders and
narcissistic personality disorders. It is also one of the treatments
recommended for patients with borderline personality disorders, although
special variations may be required to deal with the associated turbulent personality
characteristics, primitive defense mechanisms, tendencies toward regressive
episodes, and irrational attachments to the analyst.
Brief Psychodynamic Psychotherapy
The growth of psychotherapy in general and of dynamic psychotherapies derived
from the psychoanalytic framework in particular represents a landmark
achievement in the history of psychiatry. Brief psychodynamic psychotherapy has
gained widespread popularity, partly because of the great pressure on health care
professionals to contain treatment costs. It is also easier to evaluate treatment
efficacy by comparing groups of persons who have had short-term therapy for
mental illness with control groups than it is to measure the results of long-term
psychotherapy. Thus, short-term therapies have been the subject of
much research, especially on outcome measures, which have found them to be
effective .Brief psychodynamic psychotherapy is a time-limited treatment (10 to 12
sessions) that is based on psychoanalysis and psychodynamic theory. It is used to
help persons with depression, anxiety, and posttraumatic stress disorder, among
others. There are several methods, each having its own treatment technique and
specific criteria for selecting patients; however, they are more similar than
different.
TYPES
Brief Focal Psychotherapy (Tavistock–Malan)
Brief focal psychotherapy was originally developed in the 1950s by the Balint
team at the Tavistock Clinic in London. Malan, a member of the team, reported the
results of the therapy. Malan’s selection criteria for treatment included eliminating
absolute contraindications, rejecting patients for whom certain dangers seemed
inevitable, clearly assessing patients’ psychopathology, and determining patients’
capacities to consider problems in emotional terms, face disturbing material,
respond to interpretations, and endure the stress of the treatment. Malan found that
high motivation invariably correlated with a successful outcome. Contraindications
to treatment were serious suicide attempts ,substance dependence, chronic alcohol
abuse, incapacitating chronic obsessional symptoms,incapacitating chronic phobic
symptoms, and gross destructive or self-destructive acting
Time-Limited Psychotherapy (Boston University–Mann)
A psychotherapeutic model of exactly 12 interviews focusing on a specified central
issue was developed at Boston University by James Mann and his colleagues in the
early 1970s.In contrast with Malan’s emphasis on clear-cut selection and rejection
criteria, Mann has not been as explicit about the appropriate candidates for time-
limited psychotherapy. Mann considered the major emphases of his theory to be
determining a patient’s central conflict reasonably correctly and exploring young
persons’ maturational crises with many psychological and somatic complaints.
Mann’s exceptions, similar to his rejection criteria, include persons with major
depressive disorder that interferes with the treatment agreement, those with acute
psychotic states, and desperate patients who need, but cannot
tolerate, object relations.
Short-Term Dynamic Psychotherapy (McGill University–Davanloo)
As conducted by Davanloo at McGill University, short-term dynamic
psychotherapy encompasses nearly all varieties of brief psychotherapy and crisis
intervention. Patients treated in Davanloo’s series are classified as those whose
psychological conficts are predominantly oedipal, those whose conflicts are not
oedipal, and those whose conflicts have more than one focus. Davanloo also
devised a specific psychotherapeutic technique
for patients with severe, long-standing neurotic problems, specifically those with
incapacitating obsessive-compulsive disorders and phobias. Short-Term Anxiety-
Provoking Psychotherapy (Harvard University–Sifneos)
Sifneos developed short-term anxiety-provoking psychotherapy at the
Massachusetts General Hospital in Boston during the 1950s. He used the following
criteria for selection: a circumscribed chief complaint (implying a patient’s ability
to select one of a variety of problems to be given top priority and the patient’s
desire to resolve the problem in treatment), one meaningful or give-and-take
relationship during early childhood, the ability to interact flexibly with an
evaluator and to express feelings appropriately, above average psychological
sophistication (implying not only above-average intelligence but also an ability to
respond to interpretations), a specific psychodynamic formulation (usually a set of
psychological conflicts underlying a patient’s difficulties and centering on an
oedipal focus), a contract between therapist and patient to work on the specified
focus and the formulation of minimal expectations of outcome, and good to
excellent motivation for
change, not just for symptom relief.

Behavioural Perspective

Behavioural Perspective arose in the early 20th Century in part as a reaction against
the unscientific methods of Psychoanalysis .Abnormal behaviour is the
consequence of abnormal learning from the environment .Abnormal behaviours are
learned in the same manner as normal behaviour .Behaviours whether normal or
abnormal are learned through

- Classical conditioning
- Operant conditioning
- Social learning .

 Behavioural Psychologist believed that on the study of directly observable

behavior and of the stimuli and reinforcing conditions that control it could
serve as a basis for understanding human behavior, normal and abnormal.
•Behaviorist approach is grounded on a scientific view of human behavior
that implies a systematic and structured approach to counseling. This view
does not rest on a deterministic assumption that humans are a mere product
of their sociocultural conditioning.

•Behaviorists views that the person is the producer and the product of his or
her environment.
  Learning- the modification of behavior as a consequence of experience is
the central theme of the behavioral approach Behaviorists focused on the
effects of environmental conditions (stimuli) on the acquisition,
modification, and possible elimination of various types of response
patterns, both adaptive and maladaptive.
 The current trend in behavior therapy is toward developing procedures that
actually give control to clients and thus increase their range of freedom.
 Behavior therapy aims to increase people’s skills so that they have more
options for responding. By overcoming debilitating behaviors that restrict
choices, people are freer to select from possibilities that were not available
earlier, increasing individual freedom.
Basic Characteristics and Assumptions
Six key characteristics of behavior therapy are
1.Behavior therapy is based on the principles and procedures of the scientific
method.

2.Behavior therapy deals with the client’s current problems and the factors
influencing them, as opposed to an analysis of possible historical determinants.

3.Clients involved in behavior therapy are expected to assume an active role by

engaging in specific actions to deal with their problems.

4.This approach assumes that change can take place without insight into
underlying dynamics.

5.The focus is on assessing overt and covert behavior directly, identifying the
problem, and evaluating change.

6.Behavioral treatment interventions are individually tailored to specific problems

experienced by clients.

The Therapeutic Process Therapeutic Goals

•Goals of behavior therapy are to increase personal choice and to create new
conditions for learning. The client, with the help of the therapist, defines specific
treatment goals at the outset of the therapeutic process.
•Continual assessment throughout therapy determines the degree to which
identified goals are being met.

•Contemporary behavior therapy stresses clients’ active role in deciding about their
treatment.

•The therapist assists clients in formulating specific measurable goals. Goals must
be clear, concrete, understood, and agreed on by the client and the counselor.

• The counselor and client discuss the behaviors associated with the goals, the
circumstances required for change, the nature of sub-goals, and a plan of action to
work toward these goals.

Therapist’s Function and Role

Behavior therapists conduct a thorough functional assessment (or behavioral
analysis) to identify the maintaining conditions by systematically gathering in-
formation about
•Situational antecedents,
•Dimensions of the problem behavior, and
•Consequences of the problem. The ABC model, addresses antecedents, behaviors,
and consequences. ABC model of behavior suggests that behavior (B) is
influenced by some particular events that precede it, called antecedents (A), and by
certain events that follow it called consequences (C).

Based on a comprehensive functional assessment, the therapist formulates initial

treatment goals and designs and implements a treatment plan to accomplish these
goals.
• The behavioral clinician uses strategies that have research support for use with a
particular kind of problem. These strategies are used to promote generalization and
maintenance of behavior change.
• The clinician evaluates the success of the change plan by measuring progress
toward the goals throughout the duration of treatment. Outcome measures are
given to the client at the beginning of treatment (called a baseline) and collected
again periodically during and after treatment to determine if the strategy and
treatment plan are working.
• A key task of the therapist is to conduct follow-up assessments to see whether the
changes are durable over time. Clients learn how to identify and cope with
potential setbacks. The emphasis is on helping clients maintain changes over time
and acquire behavioral and cognitive coping skills to prevent relapses.

Client’s Experience in Therapy

•It provides the therapist with a well-defined system of procedures to employ.

•Both therapist and client have clearly defined roles, and the importance of client
awareness and participation in the therapeutic process is stressed.

•Behavior therapy is characterized by an active role for both therapist and client. A
large part of the therapist’s role is to teach concrete skills through the provision of
instructions, modeling, and performance feedback.

•The client engages in behavioral rehearsal with feedback until skills are well
learned and generally receives active homework assignments (such as self-
monitoring of problem behaviors) to complete between therapy sessions.

Applied Behavioral Analysis:

Operant Conditioning Techniques Applied behavior analysis offers a functional
approach to understanding clients’ problems and addresses these problems by
changing antecedents and consequences (the ABC model). Behaviorists believe we
respond in predictable ways because of the gains we experience (positive
reinforcement) or because of the need to escape or avoid unpleasant consequences
(negative reinforcement). The goal of reinforcement, whether positive or negative,
is to increase the target behavior. Relaxation training Relaxation training involves
several components that typically require from 4 to 8 hours of instruction. Clients
are given a set of instructions that teaches them to relax. They assume a passive
and relaxed position in a quiet environment while alternately contracting and
relaxing muscles. Deep and regular breathing is also associated with producing
relaxation.
Systematic Desensitization
Systematic desensitization, which is based on the principle of classical
conditioning, is a basic behavioral procedure developed by Joseph Wolpe, one of
the pioneers of behavior therapy. Clients imagine successively more anxiety-
arousing situations at the same time that they engage in a behavior that competes
with anxiety. Gradually, or systematically, clients become less sensitive
(desensitized) to the anxiety-arousing situation.
 In Vivo Exposure and Flooding Exposure therapies are designed to treat fears and
other negative emotional responses by introducing clients, under carefully
controlled conditions, to the situations that contributed to such problems. Exposure
is a key process in treating a wide range of problems
Systematic Desensitization Systematic desensitization, which is based on the
principle of classical conditioning, is a basic behavioral procedure developed by
Joseph Wolpe, one of the pioneers of behavior therapy. Clients imagine
successively more anxiety-arousing situations at the same time that they engage in
a behavior that competes with anxiety. Gradually, or systematically, clients
become less sensitive (desensitized) to the anxiety-arousing situation.
In Vivo Exposure and Flooding Exposure therapies are designed to treat fears and
other negative emotional responses by introducing clients, under carefully
controlled conditions, to the situations that contributed to such problems. Exposure
is a key process in treating a wide range of problems associated with fear and
anxiety. Exposure therapy involves systematic confrontation with a feared
stimulus, either through imagination or in vivo (live). Whatever the route used,
exposure involves contact by clients and what they find fearful associated with fear
and anxiety. Exposure therapy involves systematic confrontation with a feared
stimulus, either through imagination or in vivo (live). Whatever the route used,
exposure involves contact by clients and what they find fearful
IN VIVO EXPOSURE :

In vivo exposure involves client exposure to the actual anxiety-evoking events

rather than simply imagining these situations. Live expo-sure has been a
cornerstone of behavior therapy for decades. Together, the therapist and the client
generate a hierarchy of situations for the client to encounter in ascending order of
difficulty.

FLOODING :

Flooding, refers to either in vivo or imaginal exposure to anxiety-evoking stimuli

for a prolonged period of time. In vivo flooding consists of intense and prolonged
exposure to the actual anxiety-producing stimuli. Remaining exposed to feared
stimuli for a pro-longed period without engaging in any anxiety-reducing
behaviors allows the anxiety to decrease on its own.. In flooding, clients are
prevented from engaging in their usual maladaptive responses to anxiety-arousing
situations.

Eye Movement Desensitization and Reprocessing :

Eye movement desensitization and reprocessing (EMDR) is a form of exposure
therapy that involves imaginal flooding, cognitive restructuring, and the use of
rapid, rhythmic eye movements and other bilateral stimulation to treat clients who
have experienced traumatic stress.

Social Skills Training Social skills training:

deals with an individual’s ability to interact effectively with others in various

social situations; it is used to correct deficits clients have in interpersonal
competencies. Social skills involve being able to communicate with others in a
way that is both appropriate and effective. Social skills training includes psycho-
education, modeling, reinforcement, behavioral rehearsal, role playing, and
feedback.

ASSERTION TRAINING:

Assertion Training is teaching people how to be assertive in a variety of social

situations. Many people have difficulty feeling that it is appropriate or right to
assert themselves. People who lack social skills frequently experience
interpersonal difficulties at home, at work, at school, and during leisure time.
Assertion training can be useful for those (1) who have difficulty expressing anger
or irritation, (2) who have difficulty saying no, (3) who are overly polite and allow
others to take advantage of them, (4) who find it difficult to express affection and
other positive responses, (5) who feel they do not have a right to express their
thoughts, beliefs, and feelings, or (6) who have social phobias.

In self-modification programs
people make decisions concerning specific behaviors they want to control or
change. People frequently discover that a major reason that they do not attain their
goals is the lack of certain skills or unrealistic expectations of change. Hope can be
a therapeutic factor that leads to change, but unrealistic hope can pave the way for
a pattern of failures in a self-change program. Basic steps
1.Selecting goals.
2. Translating goals into target behaviors.
3. Self-monitoring.
4.Working out a plan for change.
5.Evaluating an action plan..

Limitations and Criticisms of Behavior Therapy

1)Behavior therapy may change behaviors, but it does not change feelings. Some
critics argue that feelings must change before behavior can change. Behavioral
practitioners hold that empirical evidence has not shown that feelings must be
changed first, and behavioral clinicians do in actual practice deal with feelings as
an overall part of the treatment process. A general criticism of both the behavioral
and the cognitive approaches is that clients are not encouraged to experience their
emotions. In concentrating on how clients are behaving or thinking, some behavior
therapists tend to play down the working through of emotional issues.

2)Behavior therapy ignores the important relational factors in therapy. The charge
is often made that the importance of the relationship between client and therapist is
discounted in behavior therapy. Behavior therapy does not provide insight. If this
assertion is indeed true, behavior therapists would probably respond that insight is
not a necessary requisite for behavior change. A change in behavior often leads to
a change in understanding or to insight, and often it leads to emotional changes. 4.
Behavior therapy treats symptoms rather than causes. The psychoanalytic
assumption is that early traumatic events are at the root of present dysfunction.
Behavior therapists may acknowledge that deviant responses have historical
origins, but they contend that history is seldom important in the maintenance of
current problems. 5. Behavior therapy involves control and manipulation by the
therapist. All therapists have a power relationship with the client and thus have
control. Behavior therapists are just clearer with their clients about this role
believes no issues of control and manipulation are associated with behavioral
strategies that are not also raised by other therapeutic approaches

Cognitive Perspective

Assumptions of cognitive perspective

 This is concerned with the study of mental processes such as memory,
language production, thinking & reasoning and perception All behaviour is
determined by mental processes within the brain such as memory, language
& problem solving. These processes can not be directly observed & have to
be inferred by scientific measurement. Humans use cognitive processes to
make sense of the world around them. Cognitive psychologists suggest that
we use our senses to collect information from the outside world, e.g. sight,
and then we use internal mental processes to interpret this information.
 Examples of these processes are memory, language, attention, decision
making and perception. These processes all work together in order for us to
understand the world. These processes all occur very quickly and often are
automatic. For example, if a friend asks you a question you will first pay
attention to what is being said, use language processing to interpret the
sounds, then call on your memory to recall relevant information and then
formulate an answer.
 Our minds work like computers: they are information processors. The brain
inputs, stores and outputs information, and this is the best way of explaining
our thinking and behaviour.
 Cognitive psychologists suggest that the human mind works in a similar way
to a computer. A computer will receive an input, e.g. from a keyboard,
process it, through display and storage, and then output, recalling a
document previously saved. The human mind works in a similar manner.
Our senses work as an input, information is then stored and retrieved when
needed. Imagine your teacher is teaching you about the computer analogy:
you listen to their explanation (input), rehearse it (process) and then when
asked a question by your teacher you recall it (output). Therefore, the key
ideas are input
 The cognitive perspective focuses on the way that people’s thoughts
influence their emotions . It is assumed that abnormality is caused by
maladaptive thought processes that result in dysfunction .A fundamental
assumption is that having ‘Rational ’ or logical thoughts would help a
person’s development and maintaining of their psychological health . The
way we think about ourselves affects our perception of the world , which in
turn affects the way we view the future .These take the form of negative
thoughts about oneself , negative thoughts about others , & negative
thoughts about future . we interact with the world through our mental
representation of it . If our mental representations are in accurate or our
ways of reasoning are inadequate then our emotions and behaviour may be
disorganized .Cognitive or Cognitive behavioral perspective on abnormal
behavior focuses on how thoughts and information processing can become
distorted and lead to maladaptive emotions and behavior. Our thoughts
create feelings , feelings create behaviour and behaviour reinforced
thoughts . Thus it is the way we think about the problem rather than the
problem itself which causes the mental disorder .In short Abnormal behavior
is caused by faulty and irrational thought processes.
 One central construct for this perspective is the concept of a schema that
was adapted from cognitive psychology by Aaron Beck(Cognitive theorist
 pioneer).Schemas can be described as knowledge packets of information.
Schemas can change with experience. If you learn a new fact (and rehearse
it, this links back to internal mental processes) then your schema will adapt.
Schemas come in a variety of forms. The concept of scripts is a popular idea
in schemas. These are how we expect certain situations to unfold. Most
people have very similar scripts for social situations, e.g. that when entering
a restaurant, you first wait to be seated and end by paying the bill. A schema
is an underlying representation of knowledge that guides the current
processing of information and often leads to distortions on attention,
memory, and comprehension. People develop different schemas based on
their temperament, abilities, and experiences. Thus negative schema
triggered by a life event can lead to negative automatic thoughts which can
underpin the various cognitive biases.
• Attribution theory has also contributed significantly to the Cognitive
behavioral approach .Attribution is simply the process of assigning causes to
things that happen. We may attribute behavior to external events such as
rewards or punishments (Eg. He did if for the money), or we may assume
that the causes are internal and derive from traits within ourselves others( eg.
He did it because he is so generous)

• It is the way we think about the problem rather than the problem itself which
causes the mental disorder. Individuals react to interpret events in terms of
their perceived significance : beliefs , expectations and attitudes effect
behavior .

• Negative thoughts are unconscious and rapid responses to certain situations .

They can be identified as cognitive biases. These biases prevent the person
from focusing on positive side of life & so reinforce their negative views .

a) Minimisation : The bais towards minimizing success in life eg

attributing good exam results to luck
b) Magnification : is the tendency to magnify small events , usually set
backs , so they appear more serious than they really are
c) Overgeneralisation : refers to the tendency to reach a conclusion
about the world based on evidence from a single event
Selective abstraction : A tendency to focus on only negative side of life and
ignoring wider picture .
STRATEGIES AND TECHNIQUES
Therapy is relatively short and lasts about 25 weeks. If a patient does not improve
in this time, the diagnosis should be reevaluated. Maintenance therapy can be
carried out over years. As with other psychotherapies, therapists’ attributes are
important to successful therapy. Therapists must exude warmth, understand the life
experience of each patient, and be genuine and honest with themselves and with
their patients. They must be able to relate skillfully and interactively with their
patients. Cognitive therapists set the agenda at the
beginning of each session, assign homework to be performed between sessions,
and teach new skills. Therapist and patient collaborate actively . The three
components of cognitive therapy are didactic aspects, cognitive techniques, and
behavioral techniques.

Cognitive Techniques
The therapy’s cognitive approach includes four processes: eliciting automatic
thoughts,testing automatic thoughts, identifying maladaptive underlying
assumptions, and testing
the validity of maladaptive assumptions.
Eliciting Automatic Thoughts. Automatic thoughts, also called cognitive
distortions, are cognitions that intervene between external events and a person’s
emotional reaction to the event. For example, the belief that “people will laugh at
me when they see how badly I bowl” is an automatic thought that occurs to
someone who has been asked to go bowling and responds negatively. Another
example is the thought “She doesn’t like me” when someone passes in the hall
without saying “Hello.” Every psychopathological disorder has its own specific
cognitive profile of distorted thought, which, if known, provides a framework for
specific cognitive interventions
Testing Automatic Thoughts. Acting as a teacher, a therapist helps a patient test
the validity of automatic thoughts. The goal is to encourage the patient to reject
inaccurate or exaggerated automatic thoughts after careful examination. Patients
often blame themselves when things that are outside their control go awry. The
therapist reviews the entire situation with the patient and helps reassign the blame
or cause of the unpleasant events. Generating alternative explanations for events is
another way of undermining inaccurate and distorted automatic thoughts.
Identifying Maladaptive Assumptions. As the patient and therapist continue to
identify automatic thoughts, patterns usually become apparent. The patterns
represent rules or maladaptive general assumptions that guide a patient’s life.
Samples of such rules are “In order to be happy, I must be perfect” and “If anyone
doesn’t like me, I’m not lovable. Such rules inevitably lead to disappointments and
failure and, ultimately, to depression
Testing the Validity of Maladaptive Assumptions. Testing the accuracy of
maladaptive assumptions is similar to testing the validity of automatic thoughts. In
a particularly effective test, therapists ask patients to defend the validity of their
assumptions. For example, patients may state that they should always work up to
their potential, and a therapist may ask .

Humanistic Perspective
ASSUMPTION OF HUMANISTIC APPROACH

1 An ability to draw on knowledge that Humanistic models assume:

the centrality of “experiencing” (i.e. thinking, perceiving, sensing, remembering,

and feeling, along with the inherent meanings and actions associated with these
modes of experience) that people are essentially relational beings and are best
helped through authentic, person-to-person relationships that human beings are
free to act in relation to their worlds, and consequently therapeutic change will be
largely founded on self-determination and self-direction that the diversity of
human experience is to be valued and treated equally the centrality of the
assumption that people are motivated towards self-maintenance, psychological
growth and development, and hence the realisation of their potential that the
process of psychological growth and self-development operates throughout the life
span An ability to draw on knowledge that human experience can be viewed from
multiple perspectives (e.g. intrapersonal, interpersonal, contextual, cultural and
spiritual) and that as a consequence the sum of a person’s experience is greater
than each of these parts

 Knowledge of humanistic theories of human growth and development

and the origins of psychological distress
An ability to draw on knowledge that healthy functioning involves experiencing in
an integrated, holistic manner (and hence the focus of therapy is on the person as a
whole (rather than particular symptoms or specific areas of functioning)) An ability
to draw on knowledge that a capacity for integrated experiencing (and hence the
fulfillment of one’s potential) can be affected by conflicts within the self An ability
to draw on knowledge that psychological growth will be influenced by and takes
place within a social context An ability to draw on knowledge that people have a
fundamental capacity to sense whether an action contributes to growth that
emotional experiencing plays a key role in this awareness An ability to draw on
knowledge that human functioning and behavior are guided by the individual’s
subjective reality.
An ability to draw on knowledge that people have a fundamental need for
positive regard from significant others that the absence of positive regard during
the formative years adversely affects psychological development that the need to
gain positive regard under adverse conditions results in
the internalization of the values and attitudes of others, leading to: internal conflict
and disruption
of the growth process the denial and distortion of experience in an attempt to
reduce the anxiety caused by internal conflict inflexible evaluation of experience
and unquestioning acceptance of
firmly held beliefs about self and the world a reliance on the opinions and
directions of others and
the inability to trust their own judgement An ability to draw on knowledge that
people have the
potential to develop a reflexive stance, allowing them to expand self awareness &
reconstruct experiences make changes to their ways of functioning and living
 Knowledge of the humanistic conditions for, and goals of, therapeutic
change
An ability to draw on knowledge that responding empathically to clients increases
their self understanding and reduces their sense of isolation and alienation An
ability to draw on knowledge that to offer a warm, accepting and non-judgemental
attitude reduces defensiveness in the client and increases contact with the
experiencing self An ability to draw on knowledge that being genuine and
transparent increases levels of trust and models psychological health An ability to
draw on knowledge that change is more likely when: therapist and client are in
“psychological contact”:
that therapist and client are aware of and respond to each other’s presence that
therapist and client are able to communicate and relate to each other mutual
understanding exists between therapist and client the client collaborates with the
therapist to decide the course and content of the therapy
An ability to draw on knowledge of humanistic theories of therapeutic process,
particularly that: when clients experience themselves as fully accepted and
understood by the therapist this helps them to move from psychological rigidity
towards greater fluidity and hence to change: from being unaware of their own
emotional experiencing towards fuller awareness and expression of feelings
in the present moment from being unaware of firmly held beliefs about oneself and
the world
towards a position where these beliefs are recognized, evaluated and, where
appropriate, revised
from a lack of integration towards greater unity of experiencing from an inflexible
evaluation of experience (e.g. “all or nothing thinking”) towards an appreciation of
the complexity of experience
from not recognizing psychological difficulties towards experiencing problems
fully and subjectively in the present moment from externalizing experience
towards a greater sense of self-responsibility
and ownership of experience from inflexibility in interpersonal relationships
towards greater
flexibility The humanistic approach says that abnormality occurs when people are
not able to be their authentic selves .

Other Basic assumptions

• It is a psychological perspective that emphasis the study of the whole person

.

• Emphasis on people as friendly , cooperative and constructive , focus on

drive to self actualization

• Humanistic perspective views human nature as basically “good”.

• It emphasizes present conscious processes and past causes and places strong
emphasis on each person’s inherent capacity for responsible self direction.

• Humanistic psychologist emphasizes the importance of individuality. It

emphasis is thus on self-concept(Carl Rogers) and self actualizing
(A.Maslow) rather than on curing diseases or alleviating disorders.

• Values and process of choices are key in guiding behaviour and achieving
meaningful and fulfilling lives.

Client – centered therapy

 A perspective that focuses on the study of conscious experience and the

individual’s self awareness and freedom to choose and capacity for
personal growth Client-centered Therapy
 The client-centered therapy embraces the idea that a human being is
possessed of innate goodness, actualizing tendencies, and capacities for
evaluative judgments leading to “balanced, realistic, self-enhancing, other-
enhancing behaviour.” A human being becomes ineffective, hateful and
self-centred, and then incapable of making proper judgments and
 responses as the result of faulty learning. This leads to incongruence
between what is being experienced and the concept of self. Through the
medium of special kinds of relationships, it is possible for the individual to
rectify improper learning and to acquire new and productive patterns.
Release of the self-actualizing potential will lead a client to emotional
growth.
 During therapy the client, obsessed with self-criticism and self-devaluing
because of failure to live up to the idealized image, soon becomes aware of
contradictory attitudes. In the accepting and approving atmosphere of a
therapy that is totally devoid of threat and imbued with empathy, the client
becomes more tolerant of oneself and one’s failings. Tension abates and a
reintegration develops as discordance resolves between the ideal image
and the actual self-perception. Constructive personality change is thus
contingent on a number of stipulations.
 First, it is essential that the client be motivated to seek help. This is
generally in the form of some anxiety produced by an awareness of a state
of “incongruence,” in that a disparity exists between the client’s self-
picture and actual experiences.
 Second, a special kind of human contact is required. In a client-therapist
relationship, it demands
 (1) That the therapist be both empathic of the client’s awareness of his or
her own experiences and able to communicate what is going on in the
client’s inner world on the basis of this empathy,
 (2) That the therapist has ample self-awareness, is honest about personal
feelings, and is capable of “being oneself’ in the relationship in order to
function congruently, and
 (3) that the therapist possesses a positive regard for the client, accepting
fully every aspect of the client’s experience and right to be and feel as he
or she is. This does not mean that the therapist must be completely free of
deviant response patterns as long as they do not force him or her to be
authoritative and evaluating.
 Third, it is important that the client perceive, by the therapist’s behaviour
and verbalizations, that he or she is fully accepted, understood, respected,
and “cared about,” irrespective of experiences, problems, and feelings.
Entering into a relationship situation with a client-centered therapist
provides the client with a unique encounter in which he or she is neither
challenged nor condemned, every aspect of the client is respected and
accepted, and the client can yield defenses without hurt.
 The guiding principle of client-centered therapy is oriented around the fact
that the client or patient is the one responsible for his or her own destiny:
the client possesses the right of choice of solution for his or her problems,
irrespective of the choice of the therapist. Residual in each individual, it is
contended, are resources for growth that need merely be released to enable
the person to achieve maturity. The therapist strives to unleash growth
forces by refraining from imposing patterns and values on the client and
by promoting in the relationship the free expression of feeling.
 Among the activities of the client-centered therapist are
 (1) Attentive listening to the client’s communications for content and
feeling,
 (2) Responding by a friendly non-punitive, empathic attitude and by
occasional verbal comments that neither approve nor disapprove,
 (3) Pointing out the client’s feelings,
 (4) Structuring the extensions and limitations of the therapeutic
relationship,
 (5) Encouraging the client in his or her efforts to manage problems,
 (6) engaging in answering questions and giving information only when it
is essential to do so to help a client work through problems, yet avoiding
this directive role at the slightest threat of emerging dependency, and
 (7) Refraining from insight offerings, advice giving, environmental
manipulation, censure, commendation, or the posing of questions and
suggestions regarding areas of exploration.
 The Therapeutic Process
 Client-centered therapy sessions are usually scheduled once a week. More
frequent sessions, extra sessions, and phone calls are discouraged because
these can lead to a dependence that will stifle any sense of growth. The
general sequence or process of therapy has been described by Rogers as
involving a series of seven stages that the client undergoes (Meador &
Rogers, 1984). We present a highly condensed version here.
 First stage: Unwillingness to reveal self; own feelings not recognized;
rigid constructs; close relationships perceived as dangerous.
 Second stage: Feelings sometimes described, but person is still remote
from own personal experience; still externalizes heavily, but begins to
show some recognition that problems and conflicts exist.
 Third stage: Description of past feelings as unacceptable; freer flow of
expressions of self; begins to question validity of own constructs; incipient
recognition that problems are inside rather than outside the individual.
 Fourth stage: Free description of personal feelings as owned by the self;
dim recognition that long-denied feelings may break into the present;
loosening of personal constructs; some expression of self responsibility;
begins to risk relating to others on a feeling basis.
 Fifth stage: Free expression of feelings and acceptance of them; previously
denied feelings, although fearsome, are clearly in awareness; recognition
of conflicts between intellect and emotions; acceptance of personal
responsibility for problems; a desire to be what one is.
 Sixth stage: Acceptance of feelings without need for denial; a vivid,
releasing sense of experience; willingness to risk being oneself in
relationships with others; trusts others to be accepting.
 Seventh stage: Individual now comfortable with experiencing self;
experiences new feelings; little incongruence; ability to check validity of
experience.
 The client is given complete responsibility for the choice of topic, the
extent of concern with it, and the interpretation of the meanings of
reactions. The therapist’s responses are chiefly in relation to the evaluative
ideas that the client verbalizes about himself and other people, and the
feelings associated with such ideas. The role of the therapist is solely to
direct the client’s attention to his or her ideas and not to interpret or
clarify. The feelings of the individual are
 always accepted in a tolerant, non-judgmental way and are reflected back
to the person in order to bring to the client’s consciousness the full pattern
of his or her emotional attitudes. At times the rephrasing of the client’s
utterances helps the client to clarify facts. The catharsis involved in the
process, as well as the therapist’s activity in reflecting feeling, is believed
to lead to genuine self-understanding and insight in the individual’s own
terms. The release of normal growth potentials helps the client to gain
control over discordant forces in the self. The role of the therapist, thus, is
to act as a catalyst of growth, a (“change agent”) not to impose growth on
the client. Treatment, as can be seen, is oriented around the idea that the
individual has the capacity to deal effectively with those aspects of his or
her personality of which he or she becomes conscious during the
relationship with the therapist. It is assumed that the client can achieve
insight in the relationship and can accept and make constructive use of
responsibility.
 Rogers revised upward his original idea of client-centered therapy as being
most useful in essentially normal people who have sufficient personality
integrity to solve their problems with a minimum of help from the
 therapist. His contention is that his method is universally applicable from
childhood to old age, from mild adjustment difficulties to severe
psychoses, from “normal” to deeply neurotic situations, from immature
dependent people to those with strong ego development, from lower-class
to upper-class citizens, from lowly to highly intelligent persons, from
physically healthy souls to those with psychosomatic ailments.
 Criticisms of Client-centered Therapy
  Client-centered psychotherapy is tailor-made for persons who need and
respond to a kind, caring, non-judgmental atmosphere and who are ready
for and possess a strong motivation for change.
  It is helpful to individuals with a relatively sound personality structure
who require aid in clarifying their ideas about a current life difficulty or
situational impasse and who may be responsive to a “helping process.”
  It is less helpful in the treatment of emotional problems that contain
strong anxiety elements.

Existential Perspectives
This perspectives stresses the need for people to continually recreate themselves
and be self – aware , acknowledges that anxiety is a normal part of life , focuses on
free will and self –determination , emphasis that each person has a unique identity
known only through relationships and the search for meaning , and finally , that we
develop to our maximum potential . Abnormal behaviour arises when we avoid
making choices, do not take responsibility, and fail to actualize our full potential.
Psychological dysfunction is caused by self – deception: people hide from life’s
responsibilities and fail to recognize that it is up to them to give meaning to their
lives .
Dimensions of human conditions according to the existential approach.
The basic dimensions of the human condition, according to the existential
approach, include (1) the capacity for self-awareness; (2) freedom and
responsibility; (3) creating one’s identity and establishing meaningful relationships
with others; (4) the search for meaning, purpose, values, and goals; (5) anxiety as a
condition of living; and (6) awareness of death and nonbeing. I develop these
propositions in the following sections by summarizing themes that emerge in the
writings of existential philosophers and psychotherapists, and I also discuss the
implications for counseling practice of each of these propositions.
Proposition 1: The Capacity for Self-Awareness
As human beings, we can reflect and make choices because we are capable of self-
awareness. The greater our awareness, the greater our possibilities for freedom. We
increase our capacity to live fully as we expand our awareness in the following
areas:
• We are finite and do not have unlimited time to do what we want in life.
• We have the potential to take action or not to act; inaction is a decision.

• We choose our actions, and therefore we can partially create our own destiny.

• Meaning is the product of discovering how we are “thrown” or situated in the

world and then, through commitment, living creatively.

• As we increase our awareness of the choices available to us, we also increase our
sense of responsibility for the consequences of these choices.

• We are subject to loneliness, meaninglessness, emptiness, guilt, and isolation.

• We are basically alone, yet we have an opportunity to relate to other beings. We

can choose either to expand or to restrict our consciousness. Because self-
awareness is at the root of most other human capacities, the decision to expand it is
fundamental to human growth. Here are some dawning awarenesses that
individuals may experience in the counseling process

• They see how they are trading the security of dependence for the anxieties that
accompany choosing for themselves.

• They begin to see that their identity is anchored in someone else’s definition of
them; that is, they are seeking approval and confirmation of their being in others
instead of looking to themselves for affirmation.

• They learn that in many ways they are keeping themselves prisoner by some of
their past decisions, and they realize that they can make new decisions.

• They learn that although they cannot change certain events in their lives they can
change the way they view and react to these events.

• They learn that they are not condemned to a future similar to the past, for they
can learn from their past and thereby reshape their future.

• They realize that they are so preoccupied with suffering, death, and dying that
they are not appreciating living.
• They are able to accept their limitations yet still feel worthwhile, for they
understand that they do not need to be perfect to feel worthy.

• They come to realize that they are failing to live in the present moment because
of preoccupation with the past, planning for the future, or trying to do too many
things at once.

Increasing self-awareness, which includes awareness of alternatives,

motivations, factors influencing the person, and personal goals, is an aim of all
counseling.
It is the therapist’s task to indicate to the client that a price must be paid for
increased awareness. As we become more aware, it is more difficult to “go home
again.” Ignorance of our condition may have brought contentment along with a
feeling of partial deadness, but as we open the doors in our world, we can expect
more turmoil as well as the potential for more fulfillment.
Proposition 2: Freedom and Responsibility
A characteristic existential theme is that people are free to choose among
alternatives and therefore have a large role in shaping their destinies. A central
existential concept is that although we long for freedom, we often try to escape
from our freedom (Russell, 2007). Even though we have no choice about being
thrust into the world, the manner in which we live and what we become are the
result of our choices. Because of the reality of this freedom, we are challenged to
accept responsibility for directing our lives. However, it is possible to avoid this
reality by making excuses. In speaking about “bad faith,” the existential
philosopher Jean-Paul Sartre (1971) refers to the inauthenticity of not accepting
personal responsibility. Here are two statements that reveal bad faith: “Since that’s
the way I’m made, I couldn’t help what I did” or “Naturally I’m this way, because
I grew up in a dysfunctional family.” An inauthentic mode of existence consists of
lacking awareness of personal responsibility for our lives and passively assuming
that our existence is largely controlled by external forces. Sartre claims we are
constantly confronted with the choice of what kind of person we are becoming, and
to exist is never to be finished with this kind of choosing.
The Experience of Relatedness
We humans depend on relationships with others. We want to be significant in
another’s world, and we want to feel that another’s presence is important in our
world. When we are able to stand alone and dip within ourselves for our own
strength, our relationships with others are based on our fulfillment, not our
deprivation. If we feel personally deprived, however, we can expect little but a
clinging and symbiotic relationship with someone else.
Perhaps one of the functions of therapy is to help clients distinguish between a
neurotically dependent attachment to another and a life-affirming relationship in
which both persons are enhanced. The therapist can challenge clients to examine
what they get from their relationships, how they avoid intimate contact, how they
prevent themselves from having equal relationships, and how they might create
therapeutic, healthy, and mature human relationships.
Struggling with Our Identity
The awareness of our ultimate aloneness can be frightening, and some clients may
attempt to avoid accepting their aloneness and isolation. Because of our fear of
dealing with our aloneness, Farha (1994) points out that some of us get caught up
in ritualistic behavior patterns that cement us to an image or identity we acquired
in early childhood. He writes that some of us become trapped in a doing mode to
avoid the experience of being.
Part of the therapeutic journey consists of the therapist challenging clients to begin
to examine the ways in which they have lost touch with their identity, especially by
letting others design their life for them. The therapy process itself is often
frightening for clients when they realize that they have surrendered their freedom
to others and that in the therapy relationship they will have to assume their
freedom again. By refusing to give easy solutions or answers, existential therapists
confront clients with the reality that they alone must find their own answers.
Proposition 4: The Search for Meaning
Existential therapy can provide the conceptual framework for helping clients
challenge the meaning in their lives. Questions that the therapist might ask are,
“Do you like the direction of your life? Are you pleased with what you now are
and what you are becoming? If you are confused about who you are and what you
want for yourself, what are you doing to get some clarity?”
The problem of discarding old values:
One of the problems in therapy is that clients may discard
traditional (and imposed) values without finding other, suitable ones to replace
them. What does the therapist do when clients no longer cling to values that they
never really challenged or internalized and now experience a vacuum? Clients may
report that they feel like a boat without a rudder. They seek new guidelines and
values that are appropriate for the newly discovered facets of themselves, and yet
for a time they are without them. Perhaps the task of the therapeutic process is to
help clients create a value system based on a way of living that is consistent with
their way of being. The therapist’s job might well be to trust the capacity of clients
to eventually discover an internally derived value system that does provide a
meaningful life. They will no doubt flounder for a time and experience anxiety as a
result of the absence of clear-cut values. The therapist’s trust is important in
helping clients trust their own capacity to discover a new source of values.
Meaninglessness

When the world they live in seems meaningless, clients may wonder whether it is
worth it to continue struggling or even living. Faced with the prospect of our
mortality, we might ask: “Is there any point to what I do now, since I will
eventually die? Will what I do be forgotten when I am gone? Given the fact of
mortality, why should I busy myself with anything? For Frankl (1978) such a
feeling of meaninglessness is the major existential neurosis of modern life.

Meaninglessness in life can lead to emptiness and hollowness, or a condition that

Frankl calls the existential vacuum. This condition is often experienced when
people do not busy themselves with
routine or with work. Because there is no preordained design for living, people are
faced with the task of creating their own meaning. At times people who feel
trapped by the emptiness of life withdraw from the struggle of creating a life with
purpose. Experiencing meaninglessness and establishing values that are part of a
meaningful life are issues that become the heart of counseling.
Creating New Meaning
Logotherapy is designed to help clients find a meaning in life. The
therapist’s function is not to tell clients what their particular meaning in life should
be but to point out that they can discover meaning even in suffering (Frankl, 1978).
This view holds that human suffering (the tragic and negative aspects of life) can
be turned into human achievement by the stand an individual takes when faced
with it. Frankl also contends that people who confront pain, guilt, despair, and
death can challenge their despair and thus triumph. Yet meaning is not something
that we can directly search for and obtain. Paradoxically, the more rationally we
seek it, the more likely we are to miss it. Yalom (2003) and Frankl (1978) are in
basic agreement that, like pleasure, meaning must be pursued obliquely.
Proposition 5
Anxiety as a Condition of Living
Anxiety arises from one’s personal strivings to survive and to maintain and assert
one’s being, and the feelings anxiety generates are an inevitable aspect of the
human condition. Existential anxiety is the unavoidable result of being confronted
with the “givens of existence”—death, freedom, choice, isolation, and
meaninglessness (Vontress, 2008; Yalom, 1980). Existential anxiety can be a
stimulus for growth. We experience this anxiety as we become increasingly aware
of our freedom and the consequences of accepting or rejecting that freedom. In
fact, when we make a decision that involves reconstruction of our life, the
accompanying anxiety can be a signal that we are ready for personal change. If we
learn to listen to the subtle messages of anxiety, we can dare to take the steps
necessary to change the direction of our lives. Existential therapists differentiate
between normal and neurotic anxiety, and they see anxiety as a potential source of
growth. Being psychologically healthy entails living with as little neurotic anxiety
as possible, while accepting and struggling with the unavoidable existential anxiety
(normal anxiety) that is a part of living.

Many people who seek counseling want solutions that will enable them to
eliminate anxiety. Although attempts to avoid anxiety by creating the illusion that
there is security in life may help us cope with the unknown, we really know on
some level that we are deceiving ourselves when we think we have found fixed
security. We can blunt anxiety by constricting our life and thus reducing choices.
Opening up to new life, however, means opening up to anxiety.
The existential therapist can help clients recognize that learning how to tolerate
ambiguity and uncertainty and how to live without props can be a necessary phase
in the journey from dependence to autonomy. The therapist and client can explore
the possibility that although breaking away from crippling patterns and building
new lifestyles will be fraught with anxiety for a while, anxiety will diminish as the
client experiences more satisfaction with newer ways of being. When a client
becomes more self-confident, the anxiety that results from an expectation of
catastrophe will decrease.
Proposition 6
Awareness of Death and Nonbeing
The existentialist does not view death negatively but holds that awareness of death
as a basic human condition gives significance to living. A distinguishing human
characteristic is the ability to grasp the reality of the future and the inevitability of
death. It is necessary to think about death if we are to think significantly about life.
From Frankl’s perspective, death should not be considered a threat. Rather, death
provides the motivation for us to live our lives fully and take advantage of each
opportunity to do something meaningful (Gould, 1993).
Rather than being frozen by the fear of death, death can be viewed as a positive
force that enables us to live as fully as possible. Although the notion of death is a
wake-up call, it is also something that we strive to avoid (Russell, 2007). If we
defend ourselves against the reality of our eventual death, life becomes insipid and
meaningless. But if we realize that we are mortal, we know that we do not have an
eternity to complete our projects and that the present is crucial. Our awareness of
death is the source of zest for life and creativity. Death and life are interdependent,
and though physical death destroys us, the idea of death saves us (Yalom, 1980,
2003).
Yalom (2003) recommends that therapists talk directly to clients about the
reality of death. He believes the fear of death percolates beneath the surface and
haunts us throughout life. Death is a visitor in the therapeutic process, and Yalom
believes that ignoring its presence sends the message that death is too
overwhelming to explore. Confronting this fear can be the factor that helps us
transform an inauthentic mode of living into a more authentic one (Yalom, 1980).

One focus in existential therapy is on exploring the degree to which clients are
doing the things they value. Without being morbidly preoccupied by the ever-
present threat of nonbeing, clients can develop a healthy awareness of death as a
way to evaluate how well they are living and what changes they want to make in
their lives. Those who fear death also fear life. When we emotionally accept the
reality of our eventual death, we realize more clearly that our actions do count, that
we do have choices, and that we must accept the ultimate responsibility for how
well we are living (Corey & Corey, 2006).
Existential anxiety?
Existential anxiety can be a stimulus for growth. We experience this anxiety as we
become increasingly aware of our freedom and the consequences of accepting or
rejecting that freedom. In fact, when we make a decision that involves
reconstruction of our life, the accompanying anxiety can be a signal that we are
ready for personal change. If we learn to listen to the subtle messages of anxiety,
we can dare to take the steps necessary to change the direction of our lives.
Normal anxiety according to existential approach.
Normal anxiety is an appropriate response to an event being faced. Further, this
kind of anxiety does not have to be repressed, and it can be used as a motivation to
change. Because we could not survive without some anxiety, it is not a therapeutic
goal to eliminate normal anxiety.

Neurotic anxiety according to existential approach.

Neurotic anxiety, in contrast, is out of proportion to the situation. It is typically out

of awareness, and it tends to immobilize the person. Being psychologically healthy
entails living with as little neurotic anxiety as possible, while accepting and
struggling with the unavoidable existential anxiety (normal anxiety) that is a part
of living.

Limitations and Criticisms of the Existential Approach.

A major criticism often aimed at this approach is that it lacks a systematic
statement of the principles and practices of psychotherapy. Some practitioners have
trouble with what they perceive as its mystical language and concepts. Some
therapists who claim adherence to an existential orientation describe their
therapeutic style in vague and global terms such as self-actualization, dialogic
encounter, authenticity, and being in the world. This lack of precision causes
confusion at times and makes it difficult to conduct research on the process or
outcomes of existential therapy.
Both beginning and advanced practitioners who are not of a philosophical turn of
mind tend to find many of the existential concepts lofty and elusive. And those
counselors who do find themselves close to this philosophy are often at a loss
when they attempt to apply it to practice. As we have seen, this approach places
primary emphasis on a subjective understanding of the world of clients. It is
assumed that techniques follow understanding. The fact that few techniques are
generated by this approach makes it essential for practitioners to develop their own
innovative procedures or to borrow from other schools of therapy. For counselors
who doubt that they can counsel effectively without a specific set of techniques,
this approach has limitations (Vontress, 2008).
Practitioners who prefer a counseling practice based on research contend that the
concepts should be empirically sound, that definitions should be operational, that
the hypotheses should be testable, and that therapeutic practice should be based on
the results of research into both the process and outcomes of counseling. Certainly,
the notion of manualized therapy is not part of the existential perspective because
every psychotherapy experience is unique (Walsh & McElwain, 2002). From the
perspective of evidence-based practices, existential therapy is subject to criticism.
According to Cooper (2003), existential practitioners generally reject the idea that
the therapeutic process can be measured and evaluated in quantitative and
empirical ways. There is a distinct lack of studies that directly evaluate and
examine the existential approach. To a large extent, existential therapy makes use
of techniques from other theories, which makes it difficult to apply research to this
approach to study its effectiveness (Sharf, 2008).
According to van Deurzen (2002b), the main limitation of this approach is that of
the level of maturity, life experience, and intensive training that is required of
practitioners. Existential therapists need to be wise and capable of profound and
wide-ranging understanding of what it means to be human. Authenticity is a
cardinal characteristic of a competent existential practitioner, which is certainly
more involved than mastering a body of knowledge and acquiring technical skills.
Russell (2007) puts this notion nicely: “Authenticity means being able to sign your
own name on your work and your life. It means you will want to take
responsibility for creating your own way of being a therapist”.
Meaning of existential tradition.
The existential tradition seeks a balance between recognizing the limits and tragic
dimensions of human existence on one hand and the possibilities and opportunities
of human life on the other hand. It grew out of a desire to help people engage the
dilemmas of contemporary life, such as isolation, alienation, and meaninglessness.
The current focus of the existential approach is on the individual’s experience of
being in the world alone and facing the anxiety of this isolation.

 Existential perspective emphasize on the uniqueness of each individual,

the quest for values and meaning, and the existence of freedom for self
direction and self-fulfilment.
 Emphasis on self – determination, choice and individual responsibility,
focus on authenticity.
• Living is much more of a “confrontation” for the existentialists than for the
humanist

• Existentialists concerned with the inner experience of an individual in his or

her attempts to understand and deal with the deepest human problems.

• Existence & Essence- our existence is a given, but what we make of it – our
essence – is up to us.

 Meaning & Value- The will-to-meaning is a basic human tendency to find

satisfying values and guide one’s life by them
EXISTENTIAL PSYCHOTHERAPY
Existential psychotherapy is an approach to therapy originally developed by
Rollo May, Victor Frankl, and Irvin Yalom. It centres on the premise that each
person is essentially alone in the world and that realization of this fact can
overwhelm us with anxiety. This anxiety may take a number of forms and is the
root of all psychopathology. In addition to the inescapable conclusion of aloneness,
existential theory holds that other inevitabilities of human life, especially death,
contribute to a powerful sense of meaninglessness in many people. Existential
therapists place great emphasis on clients’ abilities to overcome meaninglessness
by creating their own meaning through the decisions they make. They especially
encourage clients to make choices that are true to themselves in the present and
future, rather than choices that are determined by restrictive relationships they have
had in the past. They empathize with the clients’ reactions to the unavoidable facts
of existence, but through questioning and discussion, they aid clients in assuming
control and assigning significance to their lives
Existential psychology rejects the mechanistic views of the Freudians and instead
sees people as engaged in a search for meaning. At a time when so many people
are troubled by the massive problems of a technological society and seek to repair
their alienated modes of living, existentialism has gained great popularity. It seems
to promise the restoration of meaning to life, an increased spiritual awakening, and
individual growth that will bring freedom from the conventional shackles created
by a conformist society. Hardly a unified movement that speaks with a single
voice, the existential view actually turns out to be many views. Its roots lie deep in
the philosophies of Kierkegaard, Heidegger, Tillich, Sartre, Jaspers, and others.
When we discuss the psychological applications of existentialism, names such as
Binswanger, Boss, Gendlin, Frankl, May, and Laing come to mind.
Philosophically, existentialism springs from the same sources as does
phenomenology. The existentialists make a number of assertions about human
nature. Basic to all is a fundamental human characteristic: the search for meaning.
That search is carried out through imagination, symbolization, and judgment. All
of this occurs in a matrix of
participation in society. From the standpoint of both their physical environment
and their biological environment, people function in a social context.
A crucial facet of personality is decision making, which involves the world of both
facts and possibilities. Thus, personality is not just what one is—a biological,
social, and psychological being— but also what one might become. Many
existentialists believe that decision making involves a set of inevitable choices.
One can choose the present (the status quo), which represents lack of change and a
commitment to the past. That choice will lead to guilt and remorse over missed
opportunities. But one can also choose alliance with the future. That choice propels
the person into the future with an anxiety that stems from one’s inability to predict
and control the unknown. Such experiences of guilt and anxiety are not learned but
are part of the essence of living. It requires courage to choose the future and suffer
the inevitable anxieties that this choice entails. A person can find that courage by
having faith in self and by recognizing that choosing the past will inevitably lead to
a guilt that is even more terrifying than anxiety.
The Goals of Therapy. The ultimate goal of existential psychotherapy is to help
the individual reach a point at which awareness and decision making can be
exercised responsibly. The exercise of cognitive abilities will allow for the
achievement of higher states of love, intimacy, and constructive social behaviour.
Through therapy, one must learn to accept responsibility for one’s own decisions
and to tolerate the anxiety that accumulates as one move toward change. This
involves self-trust and also a capacity to accept those things in life that are
unchangeable or inevitable.
Techniques.
Existential therapy does not emphasize techniques. Too often, techniques imply
that the client is an object to which those techniques are applied. Instead, the
emphasis is on understanding and on experiencing the client as a unique essence.
By experiencing self, the client can learn to attach meaning and value to life.
Sometimes the therapist will confront the client with questions—questions that
force the client to examine the reasons for failure to search for meaning in life. For
example, a client who repeatedly complains that his job is not very fulfilling may
be asked why he does not search for other employment or return to school for more
training. Such questions may force the client to examine his or her orientation
toward the past more closely, and this in turn creates feelings of guilt and a sense
of emptiness.
Logo therapy
One of the most widely known forms of existential therapy is logo therapy. This
technique encourages the client to find meaning in what appears to be a callous,
uncaring, and meaningless world.
Viktor Frankl developed the technique. His early ideas were shaped by the
Freudian influence. However, he moved on to an existential framework as he tried
to find ways of dealing with experiences in Nazi concentration camps. He lost his
mother, father, brother, and wife to the Nazi Holocaust and was himself driven to
the brink of death. It seemed to him that the persons who could not survive these
camps were those who possessed only the conventional meanings of life to sustain
them. But such conventional meanings could not come to grips with the realities of
the Nazi atrocities. Therefore, what was required was a personal meaning for
existence. From his wartime experiences and the existential insights that he felt
permitted him to survive, Frankl developed logo therapy (the therapy of meaning).
Many of his ideas are expressed in a series of books. Frankl’s views about
personality and his ideas about the goals of therapy are generally quite consonant
with our previous discussion of existentialism. However, it is not always clear that
logo therapy techniques bear any close or rational relationship to the theory.
Logo therapy is designed to complement more traditional psychotherapy, not to
replace it. However, when the essence of a particular emotional problem seems to
involve agonizing over the meaning or the futility of life, Frankl regards logo
therapy as the specific therapy of choice. Logo therapy then strives to inculcate a
sense of the client’s own responsibility and obligations to life (once the latter’s
meaning has been unfolded). Frankl makes much of responsibility, regarding it as
more important than historical events in the client’s life. What is crucial is the
meaning of the present and the outlook for the future.
In particular, two techniques described by Frankl (1960) have gained considerable
exposure.
Paradoxical intention is a popular technique in which the client is told to
consciously attempt to perform the very behaviour or response that is the object of
anxiety and concern. Fear is thus replaced by a paradoxical wish. For example,
suppose a client complains that she is fearful of blushing when she speaks before a
group. She would be instructed to try to blush on such occasions. According to
Frankl, the paradoxical fact is that she will usually be unable to blush when she
tries to do what she fears she will do. Typically, the therapist tries to handle all of
this in a light tone. For example, in the case of a client fearful of trembling before
his instructor, Frankl (1965) instructs the client to say to himself: “Oh, here is the
instructor! Now IL shows him how nicely I can tremble.
The second technique,
De-reflection, instructs the client to ignore a troublesome behaviour or symptom.
Many clients are exquisitely attuned to their own responses and bodily reactions.
De-reflection attempts to divert the client’s attention to more constructive activities
• And reflections.

STIGMA & ATTITUDE TOWARDS MENTAL ILLNESS

• Definition of Stigma Stigma is also a well-known factor in mental illness.

Stigma is defined as “a mark of disgrace associated with a particular
circumstance, quality, or person.” Stigma is used especially when it comes
to the mentally disabled. There is a great stigma surrounding mental health
issues . When individuals appear to be different we attach a stigma to them .
We do not do it to be cruel but we don’t understand their differences. It
causes barrier to a complete and satisfying life .People feel uncomfortable
about mental health issues than physical health.

• Addressing and eliminating the social stigma and perceived stigma attached
to mental illness has been recognized as a crucial part to addressing the
education of mental health issues.

What is Stigma

• Stigmatizing attitudes contain some core assumptions. Media portraying

mental health issues in distorted way. These media shows film and print
have identified three common misconceptions about people with mental
illness: they are homicidal maniacs who should be feared; they are
rebellious, free spirits; or they have childlike perceptions of the world that
should be marvelled. They are shown as aggressive, dangerous,
unpredictable, and violent. They use terms like psycho or crazy for
them .These representations distort the public’s view and reinforce
inaccuracies about mental health issues.

• Although stigmatizing attitudes are not confined to mental illness, the

general public seems to disapprove of persons with psychiatric disabilities
more than of persons with physical illness.
• Persons with mental illness are more likely to be seen as responsible for
causing their illness. This assumption of responsibility is less pronounced
for schizophrenia than for substance addiction and eating disorders. These
attitudes lead to corresponding discriminatory behaviour.

• Citizens are less likely to hire persons with mental illness, less likely to rent
them apartments, and more likely to falsely press charges for violent crimes.

• Another component of stigma is stereotyping.

• Stereotypes are automatic beliefs that people have about other people based
on knowing one (often trivial) thing about them. (eg. People who wear
glasses are more intelligent)

• Stigma can be perpetuated by the problem of labelling. Diagnostic labelling

can be hard to shake, even if the person later makes full recovery.

• Diagnostic classification systems do not classify people. Rather, they

classify the disorders that people have.

Public and self-stigma

• A social cognitive model of public stigma-Public stigma comprises reactions

of the general public towards a group based on stigma about that group.
Although we are used to distinguishing between groups in society and to
label these groups with different attributes, this is not a self-evident process.

• It is further important to note that labelling often implies a separation of 'us'

from 'them'. This separation easily leads to the belief that 'they' are
fundamentally different from 'us' and that 'they' even are the thing they are
labelled social psychology has identified different cognitive, emotional and
behavioural aspects of public stigma: stereotypes, prejudice, and
discrimination

• Public stigma consists of these three elements - stereotypes, prejudice and

discrimination - in the context of power differences and leads to reactions of
the general public towards the stigmatised group as a result of stigma.
 Components of Public and Self-Stigma

Public stigma

Stereotype:

• Negative belief about a group such as

• Incompetence

• Character weakness

• Dangerousness

Prejudice:

• Agreement with belief and/or

• Negative emotional reaction such as

• Anger or

• Fear

• Discrimination:

• Behaviour response to prejudice such as:

• Avoidance of work and housing opportunities

• Withholding help

Self-stigma

Stereotype:

• Negative belief about the self such as

• Incompetence

• Character weakness

• Dangerousness

Prejudice:
• Agreement with belief

• Negative emotional reaction such as

• Low self-esteem or

• Low self-efficacy

Discrimination:

• Behaviour response to prejudice such as:

• Fails to pursue work and housing opportunities

• Does not seek help

A social cognitive model of self-stigma

Self-stigma refers to the reactions of individuals who belong to a stigmatized

group and turn the stigmatizing attitudes against themselves.

• Like public stigma, self-stigma comprises of stereotyping, prejudice and

discrimination.

• First, persons who turn prejudice against themselves agree with the
stereotype: “That's right; I am weak and unable to care for myself!”

• Second, self-prejudice leads to negative emotional reactions, especially low

self-esteem and self-efficacy

• Also self-prejudice leads to behaviour responses. Because of their self-

prejudices, persons with mental illness may fail to pursue work or
independent living opportunities. Different conceptualizations of stigma

• Corrigan and colleagues focus on the cognitive and behavioural core

features of mental illness stigma: Stereotypes (cognitive knowledge
structures), prejudice (cognitive and emotional consequence of stereotypes)
and discrimination (behavioural consequence of prejudice). Focussing on
these core components, their model allows one to examine different
elements of stigmatizing attitudes and behaviours and their modifiability by
anti-stigma initiatives. It is a merit of this model that it makes it feasible to
 disentangle different phenomena underlying stigma and to make them
accessible to empirical research. In the definition of Link and Phelan,
“stigma exists when elements of labelling, stereotyping, separation, status
loss, and discrimination co-occur in a power situation that allows these
processes to unfold”.

• In their concept, stereotypes, separation, and status loss/discrimination

parallel Corrigan's stereotypes, prejudice and discrimination.

• Link and colleagues emphasize that definitions of stigma should always be

made transparent by the respective researchers, and dictionary definitions
alone such as “a mark of disgrace” are by no means sufficient.

The consequences of stigma

• Research suggests that public attitudes toward people with mental illness
seem to have become more stigmatizing over the last decades: Survey
research suggests that a representative 1996 population sample in the US
was 2.5 times more likely to endorse dangerousness stigma than a
comparable 1950 group, i.e. perceptions that mentally ill people are violent
or frightening substantially increased.

• Once you get better, you would expect to get on with life as usual however
life doesn’t always fit back into place for people with mental health issues.

• There will be rejection from community and exclusion.

Two deleterious consequences of stigma can only briefly be

mentioned here:

• First, public stigma results in everyday-life discriminations encountered by

persons with mental illness in interpersonal interactions as well as in
stereotyping and negative images of mental illness in the media.

• Second, structural discrimination includes private and public institutions that

intentionally or unintentionally restrict opportunities of persons with mental
illness.
• Two other negative consequences of stigma that are both related to the way a
person with mental illness reacts to the experience of being stigmatized in
the society:

• Self-stigma/empowerment, and

• Fear of stigma as a reason to avoid treatment.

We focus on these two aspects because both are highly relevant for
clinicians working in the mental health field. By this we do not imply that
stigma is only an individual problem. In contrast we believe stigma to be
primarily a social problem that should be addressed by public approaches.
Still, until stigma has been reduced in society, the clinician should be aware
of the meaning and consequences of stigma for individuals with mental
illness.

Self-stigma and empowerment

• Research has shown that empowerment and self-stigma are opposite poles
on a continuum.

At one end of the continuum are persons who are heavily influenced by the
pessimistic expectations about mental illness, leading to their having low
self-esteem. These are the self-stigmatized. On the other end are persons
with psychiatric disability who, despite this disability, have positive self-
esteem and are not significantly encumbered

• Many persons who are discriminated against and suffer from public stigma
do not experience self-stigma while others do

• Being stigmatized may stimulate psychological reactance so that instead of

applying the common prejudices to themselves persons oppose the negative
evaluation which results in positive self-perceptions. This fact that some
react with righteous anger to stigma, while others are indifferent to stigma
and yet another group self-stigmatizes has been called the paradox of self-
stigma and mental illness.

• While the model of self-stigma, originating in social psychological research

on other stigmatized groups (e.g. people of color, people with physical
 diseases), is useful to understand the different ways people react to stigma,
three aspects have to be included to take into account the special case of
mental illness.

• First, self-stigma resulting in decreased self-esteem and self-efficacy must

be distinguished from decreased self-esteem during depressive syndromes
that are common not only in affective disorders.

• Second, reaction to stigmatizing conditions depends on the awareness of

having a mental illness, which may be impaired during episodes of, for
instance, a psychotic condition. Third, the reaction to a stigmatizing
environment is dependent on one's perception of the subtle stigmatizing
messages from other people. This social cognition may be impaired in
serious mental illness such as schizophrenia.

Fear of stigma as a barrier to use health services

• Health belief models explain why persons choose not to take part in
treatments. These models assume that humans act rationally in ways that
diminish perceived threats (disease symptoms) and enhance perceived
benefits (improved health following treatment). Key elements in the
equation that produce health related behaviour are negative effects of
treatment, such as side-effects of medication. But of major importance is
also the effect on the social environment; i.e. being labelled and stigmatized
as a person with a mental illness after treatment Persons with mental illness
who try to avoid stigma by not pursuing psychiatric services are called
“potential consumers”. They consider themselves part of the public, are
aware of the common prejudices against persons with mental illness and do
not want to be seen as part of the “mentally ill” minority and thus avoid
public stigma. They also avoid decreased self-esteem resulting from being
mentally ill, i.e. self-stigma. The greatest single cue that produces public
stigma is the label; this label usually stems from participating in psychiatric
services. Potential consumers may opt not to access care as a way to avoid
this label.

• Further research needs to confirm the link between stigma and service use.
But the data available so far are sufficient to suggest that the reduction of
 public and self-stigma will be an important means to increase treatment
participation

Ways to reduce the stigma towards mental illness

• Three main strategies have been used to fight stigma:

1. Protest-Protest is often applied against stigmatizing public statements, media

reports and advertisements

2. Education-Education tries to diminish stigma by providing contradictory

information. Different forms like books, videos, and structured teaching
programmes have been used to convey this kind of information.

3. Contact-Contact with persons with mental illness may help to augment the
effects of education on reducing stigma

• To sum up our overview of different methods to reduce stigma, contact

combined with education seems to be the most promising avenue. Public
stigma has a major impact on many people with mental illness, especially if
it leads to self-stigma, and may interfere with various aspects of life,
including work, housing, health care, social life and self-esteem. In order to
support people with mental illness, successful long-term anti-stigma
campaigns are necessary to reduce public stigma in society.