COURSE CODE- PSY 409

COURSE TITLE- ADVANCE CLINICAL PSYCHOLOGY

STATUS-COMPULSORY
COURSE INSTRUCTOR- BABATUNDE STEPHEN I. PhD

Course outline
An Overview of Clinical Psychology
Activities and basic functions of Clinical Psychologists
Psychotherapy - Schools of Psychotherapy
- Phases of Psychotherapy
- Modalities of psychotherapy
- Ethics in psychotherapy
- Therapy Sessions
- Choosing a psychotherapist
Factors that Influence the Outcomes of Psychotherapy
Past and future of Clinical Psychology and opportunities in clinical psychology
Rehabilitation of the mentally Ill Persons
Psycho-Social Rehabilitation
The Role of Clinical Psychologists in Rehabilitation
CHALLENGES IN PSYCHOSOCIAL/MENTAL-HEALTH/PSYCHIATRIC REHABILITATION
Social-Skill Training
Vocational rehabilitation
Roles of Clinical Psychologists in Community Mental Health Delivery

AN OVERVIEW OF CLINICAL PSYCHOLOGY

As its name implies, clinical psychology is a subfield of the larger discipline of psychology.
Like all psychologists, clinical psychologists are interested in behaviour and mental
processes. Like some other psychologists, clinical psychologists generate research about
human behavior, seek to apply the results of that research, and engage in individual
assessment. Like the members of some other professions, clinical psychologists provide
assistance to those who need help with psychological problems. It is difficult to capture in a
sentence or two the ever-expanding scope and shifting directions of clinical psychology.
Nevertheless, we can outline the central features of the discipline as well as its many
variations.

Definition of Clinical Psychology

The definition of clinical psychology adopted by the American Psychological Association

Society Of Clinical Psychology; reads as follows: “The field of Clinical Psychology integrates
science, theory, and practice to understand, predict, and alleviate maladjustment,
disability, and discomfort as well to promote human adaptation, adjustment, and
personal development.

Clinical Psychology focuses on the intellectual, emotional, biological, psychological, social,

and behavioral aspects of human functioning across the life span, in varying cultures, and at
all socioeconomic levels.

Clinical psychologists work with a range of individuals, from infants to the elderly. Their
work can involve individuals themselves, families/ partners, school personnel, other health
care workers, and communities. Clinical psychologists often work in a large range of settings,
including universities, hospitals, private practice offices, or group medical practices. Of all of
the possible mental health degrees and fields available, some have described the doctoral
(Ph.D.) degree in clinical psychology to be the most versatile, since it can lead to a very wide
range of possible job opportunities.

Personal Requirements to Be a Clinical Psychologist

Certain requirements for those wishing to be clinical psychologists have more to do with
attitudes and character than with training and credentialing. Perhaps the most notable
distinguishing feature of clinical psychologists has been called the clinical attitude or the
clinical approach, which is the tendency to combine knowledge from research on human
behaviour and mental processes person. The clinical attitude sets clinicians apart from other
psychologists who search for general principles that apply to human behavior problems in
general. Clinical psychologists are interested in research of this kind, but they also want to
know how general principles shape lives, problems, and treatments on an individual level.
Because clinical psychology is both rigorously scientific and deeply personal, it requires that
people entering the field have a strong and compassionate interest in human beings.
Clinical training programs’ admissions committees look for a number of characteristics as
they make decisions about which applicants to admit to graduate study in clinical
psychology. Personality variables such as an interest in people, integrity in dealing with
others, emotional stability, and intellectual curiosity are of particular importance in
selecting candidates. These traits are important in many jobs, but they are crucial in clinical
psychology because clinicians regularly work in situations that can have significant and
lasting personal and interpersonal consequences. Even those clinical researchers who don’t
themselves offer psychotherapy may still make decisions about matters of personal
consequence to participants, so integrity, emotional stability, and sound judgment are
required for them, too.

Legal, Educational, and Ethical Requirements to Be a Clinical Psychologist

As one of psychology’s health service provider subfields, clinical psychology requires its
practitioners to receive specific training. In addition to having a degree from an accredited
institution, those who practice clinical psychology must be licensed or certified to do so by
state and national agencies. In the United States and Canada, even in Nigeria, there are
bodies that establishes the requirements for licensure in clinical psychology, awards licenses
to those who qualify, and retains the power to penalize or revoke the licenses of those who
violate licensing laws. In other words, clinical psychology, like medicine, pharmacy, law, and
dentistry, is a legally regulated profession.

Fully licensed clinicians can rent or own their own offices, set fees, establish work hours, bill
insurance companies or other third parties, consult, testify in court, and engage in a number
of other activities characteristic of independent private practice. These privileges usually
come after a trainee has completed a doctoral-level degree that includes course work,
research training, and the additional requirements listed below;

EDUCATION: How much additional education beyond the bachelor’s is required? An earned
doctorate from an accredited program is the basic educational requirement for clinical
psychology licensure Students complete substantial advanced coursework in
psychopathology, assessment, and intervention strategies, and they become involved in
conducting clinical research. Most states also require continuing education training for the
periodic renewal of licenses.

EXPERIENCE: Some term of supervised practice in the field, often embodied in successful
completion of an approved practicum, internship, or period of supervision is also a critical
part of a clinical psychologist’s required training. The duration of supervised practice varies,
but one-year and two-year internships are common. Students are typically paid a modest
stipend during their internships. As the number of persons applying for internships has
recently outpaced the number available in a given year, internship placement has become
more competitive.

TESTING OF COMPETENCE: To be licensed as a clinical psychologist, candidates must

declare to licensing boards their areas of competence, and they must pass a comprehensive
examination, often called a licensing board exam, which may include both written and oral
components.

GOOD CHARACTER: Prospective clinical psychologists must show the physical, mental, and
moral capability to engage in the competent practice of the profession. This characteristic is
often denoted by letters of recommendations and by the absence of ethical or legal
violations. Practitioners of clinical psychology should also know the ethical codes that guide
practice. It is especially useful in navigating the gray areas that invariably come up in the
practice of clinical psychology. Of course, all practitioners should know the obligations,
freedoms, and limitations that go with practice under their level of licensure and in their
state. Familiarity with the Ethics Code, as well as with state and federal laws, is necessary for
these psychologists to be effective and to avoid professional mistakes that could have
serious consequences. Most clinical psychologists hold professional licenses and provide
psychotherapy treatment, but as suggested earlier, not all do. Rather than specialize in
assessment and treatment, some choose to engage primarily in some combination of
teaching, research, consulting, or administration, while doing little or no direct service
delivery.

NOTE- Clinical psychology’s purpose is to alleviate human suffering and promote health.
Those wishing to become clinical psychologists must satisfy rigorous personal, legal, and
educational requirements.
Activities and basic functions of Clinical Psychologists

Let’s consider in more detail some of the activities that clinical psychologists pursue, the
variety of places in which they are employed, the array of clients and problems on which
they focus their attention, and the rewards of the job. Not all clinicians are equally involved
with all the activities we will describe, but our review should provide a better understanding
of the wide range of options open to those who enter the field. It might also help explain
why the field remains attractive to so many students.

About 95% of all clinical psychologists spend their working lives engaged in some
combination of six activities: assessment, treatment, research, teaching (including
supervision), consultation, and administration. psychologists in university settings will
spend more time engaged in teaching and research, and those in private practice will spend
more time conducting psychotherapy and assessment.

DIAGNOSIS/ASSESSMENT

Assessment involves collecting information about people: their behavior, problems, unique
characteristics, abilities, and intellectual functioning. This information may be used to
diagnose problematic behavior, to guide a client toward an optimal vocational choice, to
facilitate selection of job candidates, to describe a client’s personality characteristics, to
select treatment techniques, to guide legal decisions regarding the commitment of
individuals to institutions, to provide a more complete picture of a client’s problems, to
screen potential participants n psychological research projects, to establish pre-treatment
baseline levels of behavior against which to measure posttreatment improvement, and for
literally hundreds of other purposes. Most clinical assessment instruments fall into one of
three categories: tests, interviews, and observations. We cover each of these in detail in the
chapters devoted to assessment.

Clinicians today have an array of assessment options not formerly available to them. For
instance, computers can administer assessment items, analyze results, and generate entire
written reports. Another frontier of psychological assessment is developing from research
on a variety of biological factors associated with human functioning. During the last two
decades, research focusing on genetic, neurochemical, hormonal, and neurological factors
in the brain has led to the development of new neurobiological assessments. These changes,
too, have the potential to greatly enhance the assessment efforts of clinicians, but as with
computer-based assessment, they raise a number of procedural, practical, and ethical
questions.

TREATMENT/THERAPY
Clinical psychologists offer treatments designed to help people better understand and solve
distressing psychological problems. These interventions are known as psychotherapy,
behaviour modification, psychological counselling, or other terms, depending on the
theoretical orientation of the clinician. Treatment sessions may include client or therapist
monologues, painstaking construction of new behavioural skills, episodes of intense
emotional drama, or many other activities that range from the highly structured to the
utterly spontaneous.

Individual psychotherapy has long been the single most frequent activity of clinicians, but
psychologists may also treat two or more clients together in couple, family, or group
therapy. Sometimes, two or more clinicians work in therapy teams to help their clients.
Treatment may be as brief as one session or may extend over several years. Some
psychologists, known as community psychologists, focus on preventing psychological
problems by altering the institutions, environmental stressors, or behavioural skills of
people at risk for disorder (e.g., teenage parents) or of an entire community. The results of
psychological treatments are usually positive, though in some cases the change may be
small, non-existent, or even negative. Of course, increasing the effectiveness of treatments
offered to the public is a key goal of research.

RESEARCH

By training and by tradition, clinical psychologists are research oriented. For most of the first
half of its existence, the field was strongly dominated by research rather than by
application. Although that balance has changed, research continues to play a vital role in
clinical psychology.
Research activity makes clinicians stand out among other helping professions, and we
believe it is in this area that they may make their greatest contribution. In the realm of
psychotherapy, for example, theory and practice were once based mainly on case study
evidence, subjective impressions of treatment efficacy, and rather poorly designed research.
This “pre-scientific” era in the history of psychotherapy research has evolved into an
“experimental” era in which the quality of research has improved greatly and the
conclusions we can draw about the effects of therapy are much stronger. This development
is due in large measure to the research of clinical psychologists.

Clinical research varies greatly with respect to its setting and scope. Some studies are
conducted in research laboratories, while others are conducted in the more natural, but less
controllable, conditions outside the lab. Some projects are supported by governmental or
private grants that pay for research assistants, computers and other costs, but a great deal
of clinical research is performed by investigators whose budgets are limited and who
depend on volunteer help and their own ability to obtain space, equipment, and
participants.

Clinical psychology’s tradition of research is reflected in graduate school admission criteria,

which often emphasize applicants’ grades in statistics or research methods over grades in
abnormal psychology or personality theory. Many graduate departments in psychology in
the United States regard research experience as among the three most important criteria
for admission, and graduates of research-oriented clinical psychology programs typically
outperform graduates of programs that don’t emphasize research as much. Even though
most clinical psychologists do not end up pursuing a research career—many never publish a
single piece of research—most graduate programs in clinical psychology still devote a
significant amount of time to training in empirical research. Why?

There are at least four reasons. First, it is important that all clinicians be able to critically
evaluate published research so that they can determine which assessment procedures and
therapeutic interventions are likely to be effective. Second, clinicians who work in academia
must often supervise and evaluate research projects conducted by their students. Third,
when psychologists who work in community mental health centres or other service agencies
are asked to assist administrators in evaluating the effectiveness of the agency’s programs,
their research training can be very valuable. Finally, research training can help clinicians
objectively evaluate the effectiveness of their own clinical work. Tracking client change can
signal the need to change treatment plans, reveal the need for additional clinical training,
and contribute to third party (e.g., insurance companies, clinical researchers) efforts to
document and understand factors affecting clinical effectiveness.

TEACHING
A considerable portion of many clinical psychologists’ time is spent in educational activities.
Clinicians who hold full- or part-time academic positions typically teach undergraduate and
graduate courses in areas such as personality, abnormal psychology, introductory clinical
psychology, psychotherapy, behaviour modification, interviewing, psychological testing,
research design, and clinical assessment. They conduct specialized graduate seminars on
advanced topics, and they supervise the work of graduate students who are learning
assessment and therapy skills in practicum courses.

A good deal of clinical psychologists’ teaching takes the form of research supervision. This
kind of teaching begins when students and professors discuss research topics of mutual
interest that are within the professor’s area of expertise. Most research supervisors help the
student frame appropriate research questions, apply basic principles of research design to
address those questions, and introduce the student to the research skills relevant to the
problem at hand.

Clinical psychologists also do a lot of teaching in the context of in-service (i.e., on-the-job)
training of psychological, medical, or other interns, social workers, nurses, institutional
aides, ministers, police officers, prison guards, teachers, administrators, business executives,
day-care workers, lawyers, probation officers, and many other groups whose vocational
skills might be enhanced by increased psychological sophistication. Clinicians even teach
while doing therapy— particularly if they adopt a behavioural approach in which treatment
includes helping people learn more adaptive ways of behaving. Finally, many full-time
clinicians teach part time in colleges, universities, and professional schools. Working as an
adjunct faculty member provides another source of income, but clinicians often teach
because it offers an enjoyable way to share their professional expertise and to remain
abreast of new developments in their field.
CONSULTATION
Clinical psychologists often provide advice to organizations about a variety of problems. This
activity, known as consultation, combines aspects of research, assessment, treatment, and
teaching. Perhaps this combination of activities is why some clinicians find consultation
satisfying and lucrative enough that they engage in it full time. Organizations that benefit
from consultants’ expertise range in size and scope from one-person medical or law
practices to huge government agencies and multinational corporations. The consultant may
also work with neighbour-hood associations, walk-in treatment centers, and many other
community-based organizations. Consultants perform many kinds of tasks, including
education (e.g., familiarizing staff with research relevant to their work), advice (e.g., about
cases or programs), direct service (e.g., assessment, treatment, and evaluation), and
reduction of intra-organizational conflict (e.g., eliminating sources of trouble by altering
personnel assignments).

When consulting is case oriented, the clinician focuses attention on a particular client or
organizational problem and either deals with it directly or offers advice on how it might best
be handled. When consultation is program or administration oriented, the clinician focuses
on those aspects of organizational function or structure that are causing trouble. For
example, the consultant may suggest and develop new procedures for screening candidates
for various jobs within an organization, set up criteria for identifying promotable personnel,
or reduce staff turnover rates by increasing administrators’ awareness of the psychological
impact of their decisions on employees.

ADMINISTRATION
Many clinical psychologists find themselves engaged in managing or running the daily
operations of organizations. Examples of the administrative posts held by clinical
psychologists include head of a college or university psychology department, director of a
graduate training program in clinical psychology, director of a student counseling center,
head of a consulting firm or testing center, superintendent of a school system, chief
psychologist at a hospital or clinic, director of a mental hospital, director of a community
mental health center, manager of a government agency, and director of the psychology
service at a Veterans Administration (VA) hospital. Administrative duties tend to become
more common as clinicians move through their professional careers.
Although some clinical psychologists spend their time at only one or two of the six activities
we have described, most engage in more, and some perform all six. To many clinicians, the
potential for distributing their time among several functions is one of the most attractive
aspects of their field.

Employment Sites- It is evident that private practice has grown steadily over the years and
is now clearly the most frequent employment setting for clinical psychologists. University
settings are the second most common employment sites, with medical schools a distant
third, university psychological clinics, orphanages home, alcoholism treatment centers, child
treatment centers, health maintenance, public and private schools, student health and
counselling centers handicapped, medical schools, nursing homes and other geriatric
facilities, the military.

What is Psychotherapy?

Psychotherapy involves communication between patients and therapists that is intended to

help people:

• Find relief from emotional distress, as in becoming less anxious, fearful, or depressed.

• Seek solutions to problems in their lives, such as dealing with disappointment, grief, family
issues, and job or career dissatisfaction.

• Modify ways of thinking and acting that are preventing them from working productively
and enjoying personal relationships.

Psychotherapy is a treatment that involves a relationship between a therapist and patient. It

can be used to treat a broad variety of mental disorders and emotional difficulties. The goal
of psychotherapy is to eliminate or control disabling or troubling symptoms so the patient
can function better. Therapy can also help build a sense of well-being and healing.

Psychotherapy begins with some discussion of a person’s background and the concerns that
led him or her to seek help. Following this initial assessment, the patient and therapist come
to an agreement, called the treatment contract. The treatment contract specifies the goals
of treatment, treatment procedures, and a regular schedule for the time, place, and
duration of their treatment sessions. Sometimes this treatment contract is written down
explicitly, but more often it is discussed between patient and therapist.
Problems helped by psychotherapy include difficulties in coping with daily life, the impact of
trauma, medical illness, or loss, like the death of a loved one, and specific mental disorders,
like depression or eating disorders. Psychiatrists and other mental health professionals can
provide psychotherapy.

Talking with a psychotherapist differs from talking with a friend in three respects that
increase its likelihood of being helpful:

• Friends may be able and willing to listen and give advice, but qualified and duly licensed
psychotherapists are trained professionals with specialized education and experience in
understanding psychological problems.

• Whereas friendships are typically mutual relationships in which people take turns being
helpful to each other, psychotherapy is devoted entirely to the patient’s welfare.
Psychotherapy is focused solely on the patient’s needs for symptom relief, problem
solutions, or lifestyle changes.

• In contrast to the mutuality, informality, and multiple shared interests that usually
characterize friendships, psychotherapy involves a formal commitment to meet regularly at
a designated time, to talk just about the patient’s concerns, and to continue meeting as long
as doing so serves the patient’s best interests.

Many different kinds of psychotherapy have proved effective in helping people feel better,
resolve problems in living, and modify their attitudes and behavior in constructive ways.
Knowledgeable psychotherapists select and recommend a treatment approach that is
known to be well-suited for addressing a patient’s needs and concerns, and they tailor their
procedures to fit each individual patient’s personality style and life circumstances.

Aims of Psychotherapy
Psychotherapy is more than a talk between two people regarding some problem. It is a
collaborative undertaking, started and maintained on a professional level towards specific
therapeutic objectives. These are:

1. Removing existing symptoms: To eliminate the symptoms that are causing distress
and impediments is one of the prime goals in psychotherapy.
 2. Modifying existing symptoms: Certain circumstances may militate against the object
of removing symptoms (e.g. inadequate motivation, diminutive ego strength or
financial constraints); the objective can be modification rather than cure of the
symptoms.
3. Retarding existing symptoms: There are some malignant forms of problems e.g.
dementia where psychotherapy serves merely to delay an inevitable deteriorative
process. This helps in preserving client’s contact with reality.
4. Mediating disturbed patterns of behaviour: Many occupational, educational,
marital, interpersonal, and social problems are emotionally inspired. Psychotherapy
can play vital role from mere symptom relief to correction of disturbed interpersonal
patterns and relationships.
5. Promoting positive personality growth and development: Deals with the
immaturity of the normal person and characterological difficulties associated with
inhibited growth. Here psychotherapy aims at a resolution of blocks in psycho-social
development to a more complete creative self-fulfilment, more productive attitudes,
and more gratifying relationships with people. It also aims at…
– Strengthening the client’s motivation to do the right things.
– Reducing emotional pressure by facilitating the expression of feeling.
– Releasing the potentials for growth.
– Changing maladaptive habits.
– Modifying the cognitive structure of the person.
– Helping to gain self-knowledge.
– Facilitating interpersonal relations and communications.

Self-Assessment Questions 1

1) Define Psychotherapy.
2) 2) List the aims of Psychotherapy.

SCHOOLS OF PSYCHOTHERAPY

There are various schools of psychotherapy, let us now discuss them one by one.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is the most widely used evidence-based psychotherapy
for improving mental health. It helps patients identify and change thinking and behavior
patterns that are harmful or ineffective, replacing them with more accurate thoughts and
functional behaviors. It often involves practicing new skills in the “real world.”

Set of ‘talk’ psychotherapies that treat psychiatric conditions. Short-term focused

treatment. Strong empirical support with randomized clinical trials. As effective as
psychiatric medications. Recommended as critical component of treatment, particularly
when medications are contraindicated or ineffective. Why So Popular? Clear treatment
approach for patients, Assumptions make sense to patients, based on patient’s experience,
encourages practice and compliance, Patients have a sense of control and CBT works.
Common Components of CBT includes Establish good therapeutic relationship; Educate
patients - model, disorder, therapy, assess illness objectively, set goals, use evidence to
guide treatment decisions, Structure treatment sessions with agenda, Limit treatment
length and Issue and review homework to generalize learning. Behavioral Interventions-
Breathing retraining, Relaxation Behavioral activation, Interpersonal effectiveness training,
Problem-solving skill, Exposure and response prevention, Social skills training & Graded task
assignment

Psychodynamic Therapy

Psychodynamic theory begins with contribution of Sigmund Freud with the focus on
increasing ego strength and /or reducing the pressure of denied impulses, so that the client
will be free to run his own life. Psychodynamic therapy is based upon the assumption that
problems occur because of unresolved — usually unconscious — conflicts, often originating
from childhood. This therapy promotes understanding and enhances coping amongst the
clients. Free association is often used by the psychoanalysts in order to bring out the hidden
unconscious wishes and conflicts in an individual. In free association, the client is asked to
say whatever that comes to his/ her mind. This therapy also focuses on dream analysis,
because according to this therapy, during sleep there is profound relaxation of normal ego
controls than is possible in free association and hence unconscious processes are freer to
operate in sleeping than in waking thought.
Consequently, dream provides a potentially rich source of information about unconscious
needs. The analysis of transference is also the core of psychoanalytic therapy. In which the
client held strong personal feelings toward the analyst which simply could not be
understood in terms of actual events of therapy or the analyst’s character or behaviour. This
transference can be positive (like admiration, love and respect) as well as negative (hate,
contempt or anger). Freud believed that such reactions were not only barriers to therapy
but they might indeed be vehicle of therapeutic change. The essential fact about
transference is that it brings hidden and repressed feelings and conflict into the present
where they can be examined, understood and resolved.

Its which is based on the idea that behavior and mental well-being are influenced by
childhood relationships and experiences, psychological conflicts, and unproductive or
inappropriate repetitive thoughts or feelings that are often outside of the person’s
awareness. It uses the relationship with the therapist to work on understanding oneself
more fully and to change old patterns so a person can more fully take charge of his or her
life.

Psychoanalysis, which is a more intensive form of psychodynamic therapy. Sessions are

conducted three or more times a week. psychoanalysis last longer in the procedure.
Psychoanalysis is both a theory of the human mind and a therapeutic practice. It was
founded by Sigmund Freud between 1885 and 1939 and continues to be developed by
psychoanalysts all over the world. Psychoanalysis has four major areas of application: 1) as a
theory of how the mind works 2) as a treatment method for psychic problems 3) as a
method of research, and 4) as a way of viewing cultural and social phenomena like
literature, art, Behaviour Therapy

Behaviour therapy mainly deals with modifying or changing undesirable behaviour. In this
psychotherapy the maladaptive behaviours are identified and then with the help of various
techniques such behaviours are replaced or modified. Learning theories have played an
important role in behaviour therapy. And the contributions of Ivan Pavlov in terms of
classical conditioning and of B. F. Skinner in terms of operant conditioning are noteworthy.

Classical conditioning
Classical conditioning was proposed by Ivan Pavlov. His experiment in which the dog was
conditioned to salivate after ringing of the bell forms basis of this learning theory. Classical
conditioning can be described as a learning process that is a result of associations between
an environmental and a natural stimulus. Learning thus occurs due to pairing between
conditioned stimulus and unconditioned stimulus.

Operant conditioning: This learning theory was proposed by B. F. Skinner. This is also known
as instrumental conditioning. Here the learning takes place as a result of reinforcement,
reward and punishment that determine whether a particular behaviour will be repeated or
not.

Let us now discuss some of the techniques used in behaviour therapy:

• Simple Extinction: This is based on the principle that particular learned behaviour will
become weak and eventually disappear if it is not reinforced. One of the simplest ways to
decrease or eliminate a particular maladaptive behaviour is by removing the reinforcements
that encourage such behaviours. The behaviour may not be consciously reinforced but may
be unknowingly reinforced by people around the client/ client.

• Aversive Conditioning: This is based on the principle that a learned behaviour will be
weakened when it is followed by pain or punishment. Thus a maladaptive behaviour can be
reduced or removed when it is paired with pain/ punishment. Such a technique can be used
with clients/ clients with substance abuse or clients with destructive behaviours, sexual
problems, and deviant behaviours. In certain cases such a technique can also be used in
such a way that there is positive reinforcement of stimulus that are related to termination of
pain.

• Response shaping: This can be described as a process in which the responses of

individuals are shaped in such a way that he/ she is able to use responses that are not
initially present in his/ her behavioural inventory. Behaviours can also be shaped with
suitable reinforcements that lead to increase in certain behaviours.

• Assertive Training: This technique can be used to increase assertive behaviour on the part
of the client/ client. This includes appropriate expression emotions. Increased assertive can
help the client/ client by increasing his/ her wellbeing and will enhance his/ her ability to
improve social skills, achieve social rewards and can increase his/ her life satisfaction.

• The Token Economy: The focus of using tokens rather than using primary reinforces is that
they bridge the delay between the occurrences of the desired behaviour and the ultimate
reinforcement. Thus as the client makes his bed, sweeps the floor or takes on a job
responsibility, he immediately receives the requisite tokens. The goal of token economy
program is to develop behaviour that will lead to social reinforcement from others, to
enhance the skill necessary for the individual to take a responsible social role in the
institution eventually, to live successfully outside the institution. Although token economy
can be used even with those outside the institution, especially with children for increasing
desirable behaviour.

• Modelling: Response shaping can be tedious and time consuming, especially when
complex responses are to be learned, such responses can be acquired much more readily if
the subject observes a model and is then reinforced for imitating the models behaviour.
Albert Bandura developed this form of behaviour modification based on social modelling.
As a therapeutic measure, Bandura points three ways in which modelling can influence
behaviour:

1) It can serve as a basis for learning new skills and behaviour.

2) It can serve to eliminate fears and inhibitions, and

3) Finally, it can facilitate pre-existing behaviour patterns.

• Systematic Desensitization: This technique is developed by Joseph Wolpe and aims

specifically at the alleviation of maladaptive anxiety. The technique involves the pairing of
relaxation with imagined scene depicting situations that the client has indicated cause him
or her feel anxious. In this the anxiety experienced by the client are paired with relaxation,
thus helping the client systematically desensitize the anxiety while imagining about the
object or situation that provokes anxiety in him/ her. This technique has been very effective
in helping individuals deal with phobias. The process of systematic desensitization includes
the following steps:
1) The client is helped to practice relaxation technique. Deep state of relaxation can help
client deal effectively with anxieties and fear. Thus the client is asked to practice the
relaxation technique during the therapy as well as at home so that client is easily able to
practice relaxation.

2) In the second step, the client and the therapist discuss about the phobia experienced by
the client and a hierarchy of fears is created. For example, if the client is scared of lifts a list
of hierarchy is created in such a manner:

a) Looking at the lift

b) Watching people get in to the list.

c) Entering the lift

d) Entering the list and waiting inside for five minutes.

e) Entering the list and going on the first floor

f) Entering the lift and going on the fifth floor Thus in a similar manner a hierarchy of
fear is created

3) Then the client is one by one made to imagine each of the hierarchies and whenever
he/she feels slightest of anxiety he/ she is asked to practice relaxation technique.

• Implosive Therapy: Another method of behaviour therapy is Implosive therapy. This is in

a way similar to systematic desensitization technique. The technique focuses on avoidance
of anxiety arousing stimuli as a source on neurotic behaviour in an individual. The technique
involves imagination and reliving of anxiety provoking situations by the client. In this case,
rather than trying to banish the anxiety from the treatment sessions, the therapist
deliberately attempts to elicit a massive flood or “implosion” of anxiety. With repeated
exposure in safe setting, the stimulus loses its power to elicit anxiety and the neurotic
avoidance behaviour is extinguished. But because of its flooding of anxiety at the same time,
it’s unethical and used less frequently.

Humanistic Psychotherapy
Humanistic therapy is an approach where the main emphasis is on client’s subjective,
conscious experiences. The therapist’s focus is more on the present. The client plays far
active role as compared to the therapist who mainly plays the role of creating a conducive
environment.

The major form of humanistic therapy is client developed by Carl Rogers. The therapy by
Carl Rogers is known as Client Centered Therapy or more recently as Person Centered
therapy. This therapy mainly focuses on empathy, unconditional positive regard by the
therapist towards the client and communication of empathy and unconditional positive
regard by the therapist to the client.

Existential Psychotherapy
Existential approaches to psychotherapy have tended to emerge at times, and in regions the
world, where there was a groundswell of interest in existential philosophy. Frankel and Rollo
May were the major contribute Existentialism is a philosophy concerned with the meaning
of human existence. They believe that people are free to choose among alternatives
available to them have a large role in shaping their own problems of moral conflicts falls
under Logotherapy. In meaning of life for himself. This meaning I uniqueness, his destiny, his
heritage all come together to give a new meaning to his life.

Gestalt Therapy

Perls’s Gestalt therapy was born in Germany. Gestalt psychologists Wertheimer, Koffka,
Kohler, Lewin and Goldstein contributed to development of this therapy. Gestalt theory
emphasises organisation and relatedness, which is in contrast with reductionism of Wundt -
Tichner and mechanical behaviourism of applied this theory to human life, integrating the
various aspects dynamic, affective, cognitive and social in one whole and then
understanding it as a total unity.

Interpersonal Therapy

Interpersonal therapy was given by Gerald L. Klerman and Myrna Weissman based on the
ideas of Harry Stack Sullivan. As the name suggests this therapy mainly focuses on the
present and past social roles and interactions of the client. One or two problems currently
experienced by the client are taken in to consideration during the therapy. Issue related to
conflicts with friends and family member or even colleagues. It can also help individuals deal
with grief and loss. Other issues like retirement and divorce can also be dealt with this
therapy.

PHASES OF PSYCHOTHERAPY
Beginning Phase

The beginning stage of therapy has for its principle objective the establishing of a working
relationship with the client. Without such mutuality, there will be no therapeutic progress.
Because the working relationship is so vital to success in a therapy, all tasks must be
subordinated to the objective of its achievement. To ensure an adequate working
relationship the client must be motivated by:

• Clarifying and removing misconception about therapy.

• To convince the client that the therapist understands his sufferings and is capable of
helping him.

• Defining the objective of the therapy.

Middle Phase

Once the therapeutic relationship is consolidated, and the client has accepted a more active
role of working on his problem, then it’s time to enter middle stage of treatment. This has as
one of its objectives the revelation of the causes and consequences of the client’s disorder.
Middle phase is further divided into:

Early middle phase:

Main objective of early middle phase is to delineate and explore environmental frustrations
and maladaptive interpersonal drives through interviewing, and to probe unconscious
conflicts that mobilize anxiety and vitiate basic needs.

Late middle phase:

Main objective of a therapist in late middle phase is to help the client to make changes in
the maladaptive behaviour and give incentive for those changes. He also helps the client in
dealing with forces that block action, mastering the anxieties surrounding normal life goals,
correcting remediable environmental distortions, adjusting to irremediable conditions,
making adjustment to those symptoms and abnormal character patterns that for one reason
or another cannot be removed during present therapeutic effort.

Terminal Phase

Theoretically, psychotherapy is never ending since emotional growth can go on as long as

one lives. In a more usual and limited sense, psychotherapy should be terminated when the
stated goals are reached. The terminal phase necessarily begins with therapist and client
taking stock of his/her current status and future prospects and deciding whether goals are
closely enough approached. Although termination can occur even before the goals are
reached. The conditions under which termination of therapy is indicated are:

• Achievement by the client of planned treatment goals.

• Decision by the client or therapist to terminate on the basis of incomplete goals.

• The reaching of an impasse in therapy or the development of stubborn resistances that

cannot be resolved.

• Counter-transference the therapist is unable to control and

• Occurrence of physical reasons, such as moving of the residence of client or therapist.

It is also important to discuss here how long these therapies take to bring about a change in
a client. According to Frank (1973) therapeutic changes occur in phases and it starts with
restitution of well – being (remorlization), followed by a relief of symptoms (remediation)
and finally result in an improvement in functioning (rehabilitation). Obviously, in order for a
therapy to cross through all these phases adequate number of sessions will be required. But
what is that optimal number? Though it is tough to give ‘a size that fits all’ number;
however, based on the number of sessions proposed about various techniques such as CBT
and IPT, it seems 8 to 12 weeks of twice weekly sessions are required followed by
maintenance treatment at long-intervals. It is to be noted that if the client is not responding
to therapy after many sessions the therapist should re-evaluate the suitability of the
therapeutic technique chosen. Likewise, even if the client has responded well, too many
sessions might prove counterproductive or resulting in diminishing returns.

MODALITIES OF PSYCHOTHERAPY
Individual Therapy

This consists of one to one interaction between the therapist and the client. The client gets
complete and undivided attention of the therapist and thus is able to deal with his/her
specific problems effectively. This is also one of the main advantages of individual therapy.
The therapist also gets an opportunity to fully focus on the client and help him/her
adequately. However, one of the disadvantages of this therapy is that the client cannot be
observed within a social or family context.

Group Therapy

This approach is most useful when it is necessary to work on dynamics within the family
group. This therapy mainly focuses on issues involving interaction between family members
in order to improve overall functioning of the family. Family therapy addresses the concerns
of any family member, yet it is most likely to influence children, whose daily reality is
directly affected by family context. Bowen’s intergenerational model of family systems,
Structural family therapy by Minuchin are some of the family therapies that can be
effectively used.

Couple’s Therapy

As the name suggests this modality focuses mainly on the couples. It is mainly designed in
order to modify the interactions between two people in order to resolve conflict between
them. Such conflicts can be social, emotional, sexual, or economic. The therapy necessarily
involves development of therapeutic relationship with the client- couple. Techniques like
role play can be used in order to help the couple resolve the issues.

Child Therapy

The differences between adult and child psychotherapy stem from many factors such as the
nature of the problems exhibited by children, children’s dependence on adults, assessment
issues, client-therapist relationship etc. For example, most of the problems encountered in
the child are present in the normal course of development in lesser levels (e.g. aggression,
hyperactivity, anxiety), and it is a special challenge to decide whether and when to
intervene. Similarly, unlike the treatment of adults, child therapy ends by returning the
client not to his own care alone but to that of the parents. Thus the aim is not only to have
children look at themselves more squarely, but to promote a more open relationship
between children and parents that can meet their emotional needs as they grow up in a
better way (Wolff, 2000). Furthermore, children’s dependence on adults makes them
particularly vulnerable to multiple influences over which they have little control, like
parental mental health, marital and family functioning, stress in the home, difficult living
circumstances, etc. The whole problem gets compounded due to the fact that often children
are not able to give clear accounts of their problems that aggravate the dependence on
parental and other authority figure’s accounts and, at times, these accounts are highly
coloured by reporter’s own psychopathology and perception. Finally, the therapist client
relationship is, somewhat, blurred in child psychotherapy.

ETHICS IN PSYCHOTHERAPY
The psychotherapist must respect and protect civil and human rights and the central
importance of freedom of inquiry and expression in therapeutic effort. They strive to help
the public in developing informed judgments and choices concerning human behaviour. This
Ethics Code provides a common set of principles and standards upon which psychotherapist
build their professional relationship with the client. (APA, 1992)

1) When obtaining informed consent to therapy, therapist informs clients/clients early in

the therapeutic relationship about the nature and anticipated course of therapy, fees, and
involvement of third parties.

2) When the therapist is a trainee and the legal responsibility for the treatment provided
resides with the supervisor, the client/client, as part of the informed consent procedure, is
informed that the therapist is in training and is being supervised and is given the name of
the supervisor.

3) When therapist agree to provide services to several persons who have a relationship
(such as spouses, significant others, or parents and children), they take reasonable steps to
clarify at the outset, which of the individuals are clients/clients and what relationship the
therapist will have with each person. This clarification includes the therapist’s role and the
probable uses of the services provided or the information obtained.

4) If it becomes apparent that therapist may be called on to perform potentially conflicting

roles (such as family therapist and then witness for one party in divorce proceedings),
he/she should take reasonable steps to clarify and modify, or withdraw from, roles
appropriately.

5) When therapist provide services to several persons in a group setting, they describe at
the outset the roles and responsibilities of all parties and the limits of confidentiality.

6) In deciding whether to offer or provide services to those already receiving mental health
services elsewhere, therapists carefully consider the treatment issues and the potential
client’s/client’s welfare. Therapists should discuss these issues with the client/client or
another legally authorized person on behalf of the client/client in order to minimize the risk
of confusion and conflict, consult with the other service providers when appropriate, and
proceed with caution and sensitivity to the therapeutic issues.

7) Therapists do not engage in sexual intimacies with current therapy clients/ clients. They
should not engage in sexual intimacies with individuals they know to be close relatives,
guardians, or significant others of current clients/ clients. They should not accept as therapy
clients/clients persons with whom they have engaged in sexual intimacies.

8) When entering into employment or contractual relationships, therapist make reasonable

efforts to provide for orderly and appropriate resolution of responsibility for client/client
care in the event that the employment or contractual relationship ends, with paramount
consideration given to the welfare of the client/client.

9) Therapist terminate therapy when it becomes reasonably clear that the client/ client no
longer needs the service, is not likely to benefit, or is being harmed by continued service.

10) Therapist may terminate therapy when threatened or otherwise endangered by the
client/client or another person with whom the client/client has a relationship.

11) Except where precluded by the actions of clients/clients or third-party payers, prior to
termination therapists provide pre-termination counselling and suggest alternative service
providers as appropriate

Self-Assessment Question

1. What information is to be provided to the client during informed consent?

 2. What should be considered while taking decision about providing services to those
already receiving mental health services elsewhere?

FACTORS THAT INFLUENCE THE OUTCOMES OF PSYCHOTHERAPY

Let us now discuss the factors that can have an influence on the outcomes of
psychotherapy.

Nonspecific Factors

Psychotherapy attempts to alleviate emotional sufferings and enhance personality

adjustment through planned psychological interventions. But it is not the only medium
through which such benefits may be achieved. There are varieties of forces which serve to
ameliorate neurotic symptoms and sometimes under fortunate circumstances leads to
personality growth. Among the coincidental factors associated with psychological changes
are:

1) “Spontaneous” remission or cures: Spontaneous cure occurs more frequently than one
can admit because both physical and emotional difficulties are associated with periods of
exacerbation and periods of remission, and without any cause they vanish on their own.
Sometimes the most pernicious form of psychoses show tendency toward spontaneous
remission. Although we have a tendency to focus only on the evil consequences and forget
that constructive regenerative influences may be coincidently present. This indicates that
the individual has healing forces within himself that are capable of altering a presumably
fatal illness. The exact mechanisms involved in spontaneous recovery or cure are not exactly
known but a number of operative factors suggest that:

a) Life circumstances may change and open up opportunities for gratification of important
but vitiated needs, normal and neurotic.

b) Provocative stress sources may disappear as a result of the removal of the initiating
environmental irritant or because the individual extricates himself from it.

c) Crumbling and shattered defences, whose failure promotes adaptive collapse, may be
restored to their original strength, or be reinforced by new, more adequate and less
disabling defences. The return of sense of mastery in the course of buttressing failing
defences will help to return the individual to functional equilibrium.
2) Influences that automatically arise out of any “helping” situation: A brief contact with
an intelligent authority in which an emotionally disturbed person can confide brings about
relief which may satisfy the ambitions of both sufferer and helping agency. The factors
which influence helping relationships are:

a) The Placebo Effect: An individual who is suffering from physical or emotional problem and
seeking help may attach himself or herself to the instrument or person in whom he has
trust. His conviction regarding the infallibility of the object or the person may be great
enough to induce a cessation of the symptoms. When this occurs solely on the basis of
conviction or trust, it’s called placebo influence. In medical profession, placebo effect is
recognised as a potent healing force.

b) The Relationship Dimension: Every helping situation is characterised by a special kind of

relationship that develops between the therapist and subject. Implicit, if not explicit, the
individual has understanding and trust that the therapist has knowledge, skill and desire to
help him overcome the problems for which he has sought the professional help. The more
bewildered and helpless the person, the greater the reliance he places on the expert
individual. It is a most important factor in the psychotherapeutic situation, particularly at
the beginning of treatment and later when reaching the goal.

c) The Factors of Emotional Catharsis: Sometimes a sheer act of talking can provide an
individual with considerable emotional relief. It exposes suppressed attitudes and the ideas
that the person has been keeping from himself, at the same time releases tension, softens
inhibitions and liberates conscious and unconscious conflicts that have been held in check.
In the unburdening process, there is often a relief of guilt feelings in relation to past
experiences, particularly sexual acting-out, hostile or aggressive outburst and competitive
strivings.

d) The Factors of Suggestion: In any helping relationship many forces are operative,
including the need to identify oneself with helping personage who serves as a model. There
is then an unqualified tendency to assimilate the precepts and injunctions of the helper
purely on the basis of suggestion. There are a number of variables that appear to regulate
the forcefulness of suggestion (Wolberg, 1962):

• The significance to the individual of the suggesting agency.

• Significance to the subject of the specific content of offered suggestions from the helping
agency.

• Degree of anxiety that is mobilised in the subject by his acceptance of a specific suggestion
or by the relationship itself.

e) Group Dynamic: Group exerts a powerful influence on the individual. They may be
responsible for significant changes among the constituent members. The effect of alcoholic
anonymous on victims of alcohol dependence syndrome, and of the more recent on drug
addicts, are examples of how even serious personality defects may be benefitted through
constructive group adventures.

Client and Therapist Factors

Client variables

A client variable can be seen as moderators or mediators of change. There are various socio-
demographic variables of client that may affect the outcome of psychotherapy. For
example, studies have shown that CBT is more effective in reducing the depressive
symptoms in older clients. Likewise, socioeconomic status (SES) has been found to be
related to continuation of psychotherapy. A research was too to have a found a positive
relationship between higher social status and length of stay in treatment has been found.
Even gender can be a determinant of the outcome of psychotherapy. Thase et al (2000)
found across various studies that women who were manifesting more severe depression did
better in interpersonal therapy than they did in cognitive therapy.

Therapist variables

Similar to client’s variables there can be many therapist’s variable’s that can affect the
outcome of psychotherapy. For example, therapist’s age, emotional well being, aptitude and
similar other variables can have some effect on the outcome. The practice of psychotherapy
requires that the therapist possesses special personality characteristics that will enable him
to establish and to maintain the proper kind of relationship with his client. Some of the
aspects that important with regard to the therapist are:
Empathy: The most important characteristic of the good therapist is his capacity to
empathize with others. It can be explained as imagining oneself in another person’s
situation. It enables the therapist to appreciate the turmoil the client experiences in his
illness and the inevitable resistance he will manifest towards change. Lack of empathy
interferes with the respect the therapist needs to display towards the client, with the
interest to be shown in his welfare, with the ability to give him warmth and support when
needed, with the capacity to concentrate on his production and to respond appropriately.
Empathy should not be mistaken for sympathy or a tendency to overprotect the client.
Empathy means tolerance of clients making mistakes, of using his own judgment and of
developing his individual sense of values. This means that the therapist must not harbour
preconceived notions as to the kind of person he wants the client to be.

Unconditional Positive Regard: The second feature of a therapist which Carl Rogers
regarded as essential is ‘Unconditional Positive Regard.’ synonymous with this are
acceptance or warmth. By Unconditional Positive Regard Carl Rogers wished therapist to
‘prize the person’. Unconditional positive regard can be explained as being non-judgemental
and accepting the people the way they are for their uniqueness and individuality. With this
feature therapist begins their relationship with a person by directly communicating that he
accepts them, no matter how they might speak or what they might have done. The aim of
this condition is to create a climate within which the person in need can feel safe.

Genuineness: Genuineness denotes open communication. Instead of person in need trying

to guess, what therapist really means, or trying to decode the differences between what he
says and the image his body communication provides them with, there is a directness and
openness about the way therapist communicates. Genuineness on part of the therapist
encourages sharing of feelings and open communication on behalf of the client.
Genuineness on the part of the therapist will also discourage the client from pretending,
denying and concealing from the therapist.

Flexibility: Rigidity in therapist is a destructive force in psychotherapy. It prevents the

therapist from coordinating his approach with the exigencies of the therapeutic situation.
Flexibility is not only essential in the execution of technical procedure, but in other aspects
of therapy; such as, the defining of goals and setting of standards. Flexibility is also
necessary in interpreting the value system of the culture, in order to permit the relaxation
of certain austere demands in the face of which a change in client’s severity of conscience
may be thwarted.

Objectivity: Awareness of his own feelings and emotional problems helps the therapist to
remain tolerant and objective in the face of irrational controversial and provocative attitude
and behaviour manifested by the client. No matter what the client says or thinks, it is urgent
that the therapist has sufficient control over his feelings so as not to become judgmental
and, in this way, inspires guilt in the client. Objectivity tends to neutralize untoward
emotions in the therapist, particularly, over-identification, which may stifle the therapeutic
process and hostility which can destroy it. Objectivity enables the therapist to endure
attitudes, impulses and actions at variance with accepted norms. It permits the therapist to
respect the client and to realise his essential integrity, no matter how disturbed or ill he may
be.

Sensitivity: It is essential for the therapist to perceive what is happening in the treatment
process from the verbal and non-verbal behaviour of the client. Not only must the therapist
attuned to the content of the client’s communication, but he must be sensitive to the mood
and conflicts that underlie the content. He must be aware also of his own feelings and
attitudes, particularly those nurtured by his personal problems and emotional limitation that
is inspired by contact with the client. These qualities presuppose a superior intelligence and
judgment with the ability to utilise one’s intelligence in practical life problems.

Psychotherapy and Medication

The treatment of clients with psychotherapy and medication simultaneously is a common

practice throughout the world. Most mental health professionals regardless of disciplines,
emphasise the importance of psychotropic medication, in conjunction with psychotherapy.
In fact, psychotherapy and pharmacotherapy are complementary to each other from various
perspectives. For example,

• Pharmacotherapy can make amenable for psychotherapy. A client in severe depressive or

anxiety state may not show interest in psychotherapy; however, after some improvement
with medication they can reach a stage where psychotherapy can be started as they become
amenable to discuss their problems.
• Medication can increase self-esteem by decreasing feeling of hopelessness, futility and
passivity as well as enhancing the acceptability of treatment.

• Medication, for some clients works as placebo effect allowing more substantial
therapeutic alliance.

• Medication may not only increase the likelihood but also the speed and magnitude of
response to psychotherapy.

• On the other hand psychotherapy when added to an on going pharmacotherapy may have
following benefits:

– Psychotherapy promotes improved adaption and coping.

– Psychotherapy improves compliance with pharmacotherapy.

– Psychotherapy, even in clients with most severe disorder, decreases the likelihood of
recurrence of symptoms.

– Psychotherapy decreases relapses when medications are stopped.

Self-Assessment Questions

1. What are the nonspecific factors that can have an impact on the outcomes of
psychotherapy?
2. List the therapist variables that can have an impact on the outcomes of
psychotherapy

Rehabilitation of the mentally Ill Persons

Mental illness can have a wide ranging impact on the individual and can be broadly grouped
as:

a) Difficulty in learning new skills and employment.

b) Participating in social and recreational activities.

c) Establishing and maintaining relationships. d) Maintaining housing.

Not surprisingly, those with Severe Mental Illness (SMI) typified by persistent
psychopathology, marked instability characterised by frequent periods of illness or
hospitalisation and social maladaptation are more likely to have problems in all of these
domains. Thus, the goal of psychiatric rehabilitation is to develop the emotional, social and
intellectual skills needed to learn, live and work in community with the least amount of
support.

The essential elements of all rehabilitation programs are similar. These are:

a) Enable a person with mental illness to develop to the fullest extent of their capacities
despite the existence of mental illness.

b) Rehabilitation has to happen in the context of the individual’s environment.

c) Rehabilitation is directed towards utilising the individual’s strength.

d) Restoration of ‘hope’ for those with mental illness – a distinctive feature of rehabilitation.

e) Optimism about vocational potential of people with mental illness.

f) Reaching beyond work activities to cover other concerns of individuals. g) Active

involvement of individuals and primary caregivers.

h) Maintaining continued care.

i) Establishing strong relationship between patient and care-giver.

PSYCHO-SOCIAL REHABILITATION
Psychiatric rehabilitation or ‘psycho-social rehabilitation as it is now frequently termed as,
has been variously defined by authorities. Some of these are:

WHO (1980) defines it as an application of measures aimed at reducing the impact of

disability and handicapping conditions and enabling disabled people to achieve social
integration.

Anthony (1984) defines it as improving the psychiatrically disturbed persons’ capabilities

and competence by bringing about behavioural improvement in their environment of need.

Benett (1978) described psychiatric rehabilitation as helping the individual adapt to their
deficits in personal skills by making best use of his residual abilities in order to function in as
normal environment as possible.
Bachrach (1992) defined it as a therapeutic approach that encourages a mentally ill person
to develop to his or her fullest capacity through learning and environmental support.

The overall philosophy of psychiatric rehabilitation in mental disorders comprises of two

intervention strategies; namely

Individual-centered strategies: Aimed at developing patient skills in interacting with

stressful environment.

Ecological strategies: Directed towards developing environmental resources to reduce

potential stressors. Most disabled persons need a combination of both approaches.

The starting point for an adequate understanding of rehabilitation is that it is concerned

with the individual person in the context of his or her specific environment. Psychiatric
rehabilitation is regularly carried out under real life conditions. Thus, rehabilitation
practitioners have to take into consideration the realistic life circumstances that the affected
person is likely to encounter in his or her day to day living.

A necessary second step is helping disabled persons to identify their personal goals. This is
not a process where that person simply lists his/ her needs. Motivational interviews provide
a more sophisticated approach to identify the individual’s personal costs and benefits
associated with the needs listed, This makes it also necessary to assess the individual’s
readiness for change.

Subsequently the rehabilitation planning process focuses on the patient’s strengths.

Irrespective of the degree of psychopathology of a given patient, the practitioner must work
with the “well part of the ego” as “there is always an intact portion of the ego to which
treatment and rehabilitation efforts can be directed”. This leads to a closely related concept:
the aim of restoring hope to people who have suffered major setbacks in self esteem
because of their illness. According to a researcher, “it is the kind of hope that comes with
learning to accept the fact of one’s illness and one’s limitations and proceeding from there”.

Psychiatric rehabilitation cannot be imposed. Quite the contrary, psychiatric rehabilitation

concentrates on the individual’s rights as a respected partner and endorses his or her
involvement and self determination concerning all aspects of the treatment and
rehabilitation process. The rehabilitation values are also incorporated in the concept of
recovery. Within the concept of the recovery, the therapeutic alliance plays a crucial role in
engaging the patient in his or her own care planning. It is essential that the patient can rely
on his or her therapist’s understanding and trust, as most of the chronically mentally ill and
disabled persons lose intimate and stable relationship in the course of the disease. Recent
research has suggested that social support is associated with recovery from chronic
diseases, greater life satisfaction and enhanced ability to cope with life stressors. have
found that the most important factor facilitating recovery is the support of peers. Therefore,
psychiatric rehabilitation is also an exercise in network building.

Finally, people with mental disorders and their care givers prefer to see themselves as
consumers of mental health services with active interest in learning about mental disorders
and in selecting the treatment approaches. Consumerism allows the taking of the affected
persons’ perspective and seriously considering courses of action relevant for them. In this
context, physicians should also acknowledge that disagreement about the illness between
themselves and the patient is not always the result of the illness process.

As a general rule, people with psychiatric disabilities tend to have the same life aspirations
as people without disabilities in their society or culture. They want to be respected as
individuals and lead a life as normal as possible. As such they mostly desire: (a) their own
housing, (b) an adequate education and a meaningful work career, (c) satisfying social and
intimate relationships and (d) participation in community life with full rights.

The Role of Clinical Psychologist in Rehabilitation

the role of clinical psychologist in Rehabilitation is described as follows:

“A properly trained professional (clinical psychologist) will be able to prescribe psychosocial
interventions, such as social skills training, as well as prescribe medication. This does not
mean that the individual psychiatrist should be able to do everything from social skills
training to vocational rehabilitation to psycho-education to family support. It does mean,
however, that the psychiatrist must know what is needed and where it can be found and
must be able to play a role in directing a team of professionals who can serve these patients.
Not only will the patients benefit from such an approach, but so will our discipline.”

Thus, according to APA (clinical division), a clinical psychologist should be able to not only
prescribe medication (if not avoidable) for management of the disorder but also suggest
psychosocial interventions. Furthermore, a clinical psychologist may also play an important
role by contributing his/her expertise in order to help the patient.

Self-Assessment Questions

1. Define ‘Psychiatric Rehabilitation’ or psycho-social rehabilitation.

2. Discuss the two intervention strategies in psychiatric rehabilitation.

CHALLENGES IN PSYCHOSOCIAL/ PSYCHIATRIC REHABILITATION

In Nigeria and other developing countries, opportunities for rehabilitation are limited, either
due to inadequate staff, infrastructure that is rehabilitation center (RC) or training. Even
where opportunities exist, occupational activities like making envelopes or baskets, provide
little incentive and may not change the quality of life of those with mental illness (Deva,
2006). The absence of national insurance, unemployment benefits or social security
transfers the burden to family members who themselves may not be economically well off.

Moreover there are no nodal institutes at national or regional levels for mental illness, as
opposed to other disabilities. Full fledge psychosocial rehabilitation services are provided by
few departments in the country. Although the need for rehabilitation intervention may be
less as compared to developed countries, their unavailability is an issue of concern.
Government facilities for rehabilitation centers are virtually non-existent. Most RCs are
therefore operated by NGOs and trust based centers, with much of the financial aid coming
from non-government sources.

Further, issues of infrastructure and manpower, various factors are also responsible for the
poor focus on psychiatric rehabilitation. Mental illness in India has poor visibility due to a
lack of cohesive patient/family groups to showcase the problems faced by this population.
This in turn could be attributed to stigma, poverty and poor awareness, most of the
caretakers’ energies being expended on taking care of livelihood. The lack of visibility and
lobbying for patient rights lead to neglect in framing government rules and regulations,
allocation of funds as well as providing other supportive programs like vocational
opportunities etc. For example, mental illness was the last group to be recognized as causing
disability in “Persons with Disability Act”, 1995

Self-Assessment Questions
List the challenges in psychosocial/ psychiatric rehabilitation

SOCIAL SKILL TRAINING

The term ‘skills’ refers to acquired behaviours based on learning experiences. Social skills
represent constituent behaviours which when combined in appropriate sequences and used
with others in appropriate ways and places enables an individual to have success in daily
living reflected by social competence. Social competence can be defined as the ability to
achieve legitimate personal goals through interacting with others in all situations: work,
school, recreation, shopping, consumer services, medical and mental care and legal
agencies.

Thus, social skill training are heterogeneous intervention aimed at improving activities of
daily living, hygiene and grooming, basic communication skills, job-finding, and inter
personal problem solving, that is improving social competence.

Social skills and social competence can be viewed as protective factors in the vulnerability-
stress-protective factors model of schizophrenia. Strengthening social skills and competence
of individuals with schizophrenia can reduce the impact of cognitive deficits, stressful events
and social maladjustment. Improved social competence confers protection not only against
stress induced relapse but also improves interpersonal support, social affiliation and quality
of life.

Some interventions involve simple advice while other requires elaborate combination of
operant conditioning and social learning models. Steps involved in social skills training are as
follows:

1) Problem identification: Made in collaboration with patient by acknowledging ‘barriers’

and ‘goals’ of the patient.

2) Goal setting: Short-term, near-approximation goal that patient and therapist find
feasible.

3) Behaviour rehearsal or role play: Patient demonstrates the verbal, non-verbal and para-
linguistic skills required for successful social interaction.

4) Corrective feed-back: Required for behaviour exhibited in role play.

5) Social Modelling: Demonstration by the therapist of desired inter personal behaviour in a
form that can be learnt by the observing patient.

6) Behaviour practice: Facilitate its use in real-life situations.

7) Positive social reinforcement: Contingent upon those behaviour skills that showed
improvement.

8) Home-work assignment: To motivate the patient to implement the learned skill in real-
life situations.

9) Positive reinforcement and problem solving: To address issues arising in patients

experience due to the use of acquired skills.

In recent years, social skills training in psychiatric rehabilitation has become very popular
and has been widely promulgated. The most prominent proponent of skills training is Robert
Liberman, who has designed systematic and structured skills training since the mid-1970s. A
professional, Liberman and his colleagues packaged the skills training in the form of
modules with different topics. The modules focus on medication management, symptom
management, substance abuse management, basic conversational skills, interpersonal
problem solving, friendship and intimacy, recreation and leisure, workplace fundamentals,
community (re-) entry and family involvement. Each module is composed of skills areas. The
skills areas are taught in questions with demonstration videos, role-play and problem-
solving questions and in vivo and homework assignments (Liberman, 2002).

Social skills training has now been used for more than three decades in developed nations.
Studies on its efficacy in diverse treatment settings (In-patient, Out-patient, Residential
continuum), diverse practitioners (Psychiatrists, Clinical Psychologists, Mental Health Nurse,
Social Workers) and covering a broad range of skills (illness management, smoking
cessation, securing and retaining jobs) have shown gratifying results. In the last decade
there has been further refinement in the delivery of social skills training. Firstly, it is now
understood that social skills training is more effective when done in natural environment as
opposed to class-room teaching. Secondly, evidence is emerging that cognitive remediation
potentiates skills training. This has led to integration of social skills training as an essential
element in comprehensive multi-dimensional programs.
VOCATIONAL REHABILITATION
The beneficial effects of work on mental health have been known for centuries. Therefore,
vocational rehabilitation has been a core element of psychiatric rehabilitation since its
beginning. Vocational rehabilitation is based on the assumption that work does not only
improve activity, social contacts etc., but may also promote gains in related areas such as
self-esteem and quality of life, as work and employment are a step away from dependency
and a step to integration into society. Enhanced self-esteem in turn improves adherence to
rehabilitation of individuals with impaired insight.

Vocational rehabilitation originated in psychiatric institutions, where the lack of activity

and stimulation led to apathy and withdrawal of inpatients. Long before the introduction of
medication, occupational and work therapy contributed to sustainable improvements in
long-stay inpatients. Today occupational and work therapy are no longer hospital-based, but
represent the starting point for a wide variety of rehabilitative techniques teaching
vocational skills.

Vocational rehabilitation programs in the community provide a series of graded steps to

promote job entry or re-entry. For less disabled persons, brief and focused techniques are
used to teach how they can find a job, fill out applications and conduct employment
interviews. In transitional employment, a temporary work environment is provided to teach
vocational skills, which should enable the affected person to move on to competitive
employment. But all too often the gap between transitional and competitive employment is
so wide that the mentally disabled individuals remain in a temporary work environment.
Sheltered workshops providing pre-vocational training also quite often prove a dead end for
the disabled persons.

One consequence of the difficulties in integrating mentally disabled individuals into the
common labour market has been the steady growth of cooperatives, which operate
commercially with disabled and non-disabled staff working together on equal terms and
sharing management. The mental health professionals work in the background, providing
support and expertise.

Today, the most promising vocational rehabilitation model is Supported Employment (SE).
The work of Robert Drake and Deborah Becker decisively influenced the conceptualization
of SE. In their “individual placement model”, disabled persons are placed in competitive
employment according to their choices as soon as possible and receive all support needed
to maintain their position. The support provided is continued indefinitely. Participation in SE
programs is related to an increase in the ability to find and keep employment. Links were
also found between job tenure and non-vocational outcomes, such as improved self-
esteem, social integration, relationships and control of substance abuse. It was also
demonstrated that those who had found long-term employment through SE had improved
cognition and quality of life, and better symptom control.

Though, findings regarding SE are encouraging, some critical issues remain to be answered.
Many individuals in SE obtain unskilled part-time jobs. Since most studies only evaluated
short (12-18 months) follow-up periods, the long-term impact remains unclear. Currently we
do not know which individuals benefit from SE and which do not. After all, we have to
realize that the integration into the labour market does by no means only depend on the
ability of the persons affected to fulfill a work role and on the provision of sophisticated
vocational training and support techniques, but also on the willingness of society to
integrate its most disabled members.

Self-Assessment Questions
1. Discuss the steps involved in social skills training.
2. Describe supported employment as a vocational rehabilitation model?