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therapy can be debned (modibed from Wok
Derg) as. the treatment by pstchological means. of the
problenis ofan emotional nature. in sslicha therapist
ately establishes a profe:
‘). The patient is advised to signal whenever
anslety occurs. With each signal, he is asked
10 relax (Step). After a few trials, patient ts
able to control his anxiety. Thus, gradually the
berarchy is climbed! til the maximum anxtety-
Provoking stimulus can be faced in the absence
of anxiety
SD isatrea
nent of choice in phobias and obses-
sive-compulsive disorders,
Aversion Therapy
Aversion therapy
is used for the treatment of condi-
tions which
are pleasant but felt undesirable by the
Patient, e.g. alcohol dependence, transvestism, ego
dystonic homosexuality, other sexual deviations.
he underlying principle is pairing of the pleasant
stimulus (such as alcohol) with anunpleasant resp
(such as brief electrical stimulus), s0 that even
absence of unpleasant response (after the therapy is
over), the pleasant stimulus becomes unpleasant by
association, The unpleasant aversion can be produced
x
by electric stimulus (low voltage), drugs (such as apo-
morphine and disulbram) or even by Fantasy (when it
is called as covert sensitisation).
‘Typically, 20-40 sessions are needed, with each
session lasting about I hour, After completion of treat-
‘ment, booster sessions may be given. The current use
of aversion therapy has declined sharply in the Western
world (and also elsewhere) as it is felt by many that it
may violate the human rights of the patient.
Operant Conditioning Procedures for
Increasing Behaviour
The common methods for augmenting an adaptive
behaviour include:
i. Positive reinforcement: Here, the desirable
behaviour is reinforced by a reward, either
material or symbolic,
ical Treatments
Ingative retnforcement Here
Of the desitabte by
MW. Modelling: The person is exponed to
behaviour and is induced to copy i can
also be used to avold certain behaviour
Flooding
This is usually the method used in the treatment of
phobias. Here, the person is directly exposed to the
phobic stimulus, but escape is made impossible. B
prolonged contact with the phobic stimulus, therapist
guidance and encouragement, and therapist
ling behaviour, anxiety decreases and the phobic
behaviour diminishes.
2 Operant Conditioning Procedures for
Decreasing Behaviour
‘These methods include:
1. Time-out. Here, the reinforcement is withdrawn
for some time, contingent upon the undesired
response. Time-out is often used in therapy with
_ children.
il. Punishment: Aversive stimulus is here
presented, contingent upon undesired response
(Le. whenever undesired response occurs, pun-
ishment is given).
Satiation: The undesired response is positively
reinforced, so that tiring occurs. A similar tech~
nique is negative practice procedure
Other Behavioural Techniques
Many other techniques such as token economy (for
hospitalised patients), social-skills training (for
patients with social difficulties), family therapy.
marital therapy, and cognitive behavioural therapy
are available, The interested reader is referced to the
Reading List.
Cognitive Therapy or Cognitive
Behaviour Therapy
Cognitive behaviour therapy (CBT) is a type of psy-
chotherapy which aims at correcting the maladaptive
‘methods of thinking, thus providing relief from con- Hot Cross Bun Mode)
(Bkuation
Fiying
“Physiest / Physiological
“Feeling sick physically
Cryng
Breathless
Sweating
Shating
Tenors XY
SX C Behaviour,
Sayre ane:
Reads agen"
Fig. 18.1: Cognitive Behavi
sequent symptoms. The therepist plays an active role,
unlike in psychoanalysis.
Developed separately by Beck and Meichenbaum,
it is used for meatment of depression. anxiety disorder.
ic disorder, phobias, eating disorders. ent
ty, and also for teaching problem-solving meth-
ods. Some centres also use CBT for management of
“psychotic symptoms such 2s delusions and hallucina-
rz ) :
apportive Psychotherapy
tions.
Figure 18.1 illustrates the hot cross bun model o!
cognitive behaviour therapy.
A typical cognitive therapy schedule consists
of about 15 visits over a three-month period. Some
important techniques in CBT are:
i. Cognitive techniques such as recognising and
correcting negative automatic thoughts, teach-
c
ing reattribution techniques, increasing objec-
tf
assignmen
and diversion tech
iii. Tea
iv
This isa very directive method of psychott
the focus clearly on ex
fife situations. The
7. Correction of the situation:
ii, Symptom rectibcation.
Restoring or strengthening defenses Payette
Yo Hoachiayy Mey, capiny skills
Hho ali iy aehieved by a conphimeration of
eetisiques: whet include guidance, syst
ene tronmental manipulation, reaysunatice, persturstan
evelopment of a doctor pationt relations, diver
‘Sow an even hospitalisation and medication, Tits
1 highly
skilled method of psychotherapy whtel ean
provide ecettent results when used judielously
Family and Marital Therapy
Jn family therapy and marital therapy (alo ealled as
Couples therapy) the focusaF intervention bs nat on
the idea Wu sy taste ppt familly asa unto
the marital unt
There are several varietios of Family and marital
therapies, suet ay these based on psyehod
behavioural or systemic principles, Whenever the
poblents within
ily or secondary
1 psychiatric disor
4 behavioural marital therapy, components
of therapy may Include problem solving, taining In
communication skills, writing, a behavioural marital
contract, and home-work assignments,
roup Therapy
Group therapy (or group psychotherapy) is a
Tess time-consuming procedure, in which usually
(8-10 people ean be treated at one time. This was brst
used by Joseph Pratt (an internist) in 1905, for patients
suffering from tuberculosis
“Now, it is known that group therapy is not only
time-saving but also especially benebeial for certain
s10up of patients, Group therapy offers patients (and
their relatives) an_opportunity to realise that many
ters have and share problems w hich are very similar
to theit own problems, and that they are not alone in
their suffering,
Typically, sessions are held once or tw
week, with each Session lasting 1-2 hours (often 1%~
hours). The patients usually sit in a circle, with equal
opportunities for interaction. Group therapy may
ea
{wie prove hoanalytie
Hota tuna api be
Over the years, muany typos af gue
fenmerted such ws well help jrougis (Aeabtes
mous tor alcahatles, Welght Wo
Phoonty House for aplate dependent ludividuals)
Viamsaetionat Analysts geoups (Rete eve), Talat,
romps (Kurt Le
and the Hike,
supportive wthonal or
Suggestion
Although an integral part of supportive psycho
therapy, 1s aften ued alone, IIs used by nearly all
medical practitioners, without reals ns
Was sue, IIs stgestion, whtel Is tn part respon
slble for the placebo response, A placebo presertbed
conbilently by an ‘Impressive’ phystelan can lead to
improvement In about 33% of patients with
some
{unl twast conditions
G)
der), unity and/or marital therapy is indicated, For.
hypnos
Hypnosis is a state of artihelally induced (by self o
others) Inerea: gesibillty, There I
tion in the peripheral awareness with inc
concentration on task at hand,
Trance phenomena were routinely utilized by
Anton Mesmer in 1775 who called ‘this for
magnetism, The word hypnotism was brst used
james Braid in the 19th century.
Not everyone can be hypnotised. ‘The capacity
for hypnosis is called hypnotisability, which can be
‘measured in a person by using (ests such as the eye
soll sign or hand levitation test, Basically, these tests
measure suggestibility,
About 60% of the general population can be hyp.
notised but only 5-10% reach deep hypnotic trance
A wide variety of techniques are available for the
induction of hypnosis.
Following chang
hypnotic trance:
i. The person under hypnosis becomes highly
suggestible to commands of hypnotist, without
understanding their nature.
anit
by
‘occur commonly during the ii. Dissociation of a part of body or emotions from
the remainder may occur,
4ii, There is a partial or complete amnesia for the
events occurring during the hypnotic trance.
iv. There is an ability to produce or remove symp-
toms, perceptions and/or movements,
¥. Post-hypnotic suggestion cai be given just after
the trance and it is followed by the hypnotised
person.
Persons who are hypnotisable are In no way
abnormal as compared to the rest of the population,
Indications in Psychiatry
i. Asan adjunct to psychotherapy.
fi, To abreact past experiences.
The conditions in which hypnosis can help in
‘treatment are many. The most important ones are listed
below.
i, Psychosomatic disorders
i. Conversion disorder (hysteria)
Dissociative disorder (hysteria)
iv. Eating disorders (anorexia nervosa, bulimia
nervosa and obesity)
v. Habit disorders (smoking)
vi. Pain
Anxiety disorder.
vil.
Abreaction
Abreaction is an important procedure which brings to
conscious awareness, for the brst time, unconscious
conHicts and associated emotions.
The release of emotions is therapeutic. Although
abreaction is an integral part of psychoanalysis and
hypnosis, it can be used independently also. Abreac-
tion can be done with or without the use of medication.
Abreaction with Medication
longer commonly used in clinical practice, due to risk
of dependence (in case of amphetamines and LSD)
and/or side effects.
Another method is the use of 5% solution of
sodium amobarbital (amytal) or thiopentone sedium
(Pentothal), Infused ata rate no faster than I eclmin to
prevent sleep as well as respiratory depression. This
procedure must always be done very cavctully with
support from an anaesthetist who should be physically
present,
The abreactive procedure is begun with neutral
topics at brst, gradually approaching area(s) of con
Bicts. Usually about 150-350 mg (3-7 cc.) of amy
is suthcient for the purpose. In elderly znd patients
with organic brain disorder, even 75 mg of amytal
may produce excessive drowsiness.
‘The indications of amytal interview include:
i. Abreaction (mainly) e.g. in hyst
ii, Interview with a mute patient.
ii, Diagnostic test in catatonic syndrome.
iv, Differentiating test in stupor (for differential
diagnosis of depression, schizophrenia, hysteria
and organic brain disorder).
‘There are certain contraindications for the use of,
amytal interview:
i, Airway disease including upper respiratory tract
infection.
.. Severe renal or hepatic disease.
ili, History of porphyria.
iv, Hypotension
v. Dependence on barbiturates.
i. Psychosis (except for catatonia or stupor).
The other medications which have been used
successfully for abreaction include diazepam and
ketamine. The use of abreaction has declined con
siderably in the last three decades and the cur-
rent practice and guidelines do not encourage its
Earlier amphetamines, ether, nitrous oxide and Toutine use.
lysergic acid diethylamide (LSD) have been used con
abreaction. Particularly, intravenous amphetamines
were very successful as they lead to a marked increas®
in productivity of speech, thus facilitating release of
unconscious ideas and emotions. These agents are no
Relaxation Therapies
“Pe aim of these therapies is to induce muscular
relaxation. Since anxiety produces muscular tension,
~ which in turn reinforces (and thus increases) anxiety, Pry
20) telaxation technique wound decte,
Relaxation tec
Majority of behay i
desensitisation, Th
«and muscular tens! ase both anxiety
i are an integral part of a
eat theraples, such as systematl
be used to nar Het AF Many methods which ene
10 induce relaxation and these include
A. Jacobson ’s prog
is Then RreSsi.© muscular relaxation,
He most Frequently used technique. The
Patient Prt ens and then relaxes ange
Broups of eae in a prebxed and systematic
order, usually beg
ly beginning at the top of the body
progressing downwards. Se
Hypnosis
c {anscendental meditation (TM) or Yoga
‘Shavasna (The corpse posture’): Similarto pro-
SSressive relaxation but the sequence of progression
is below upwards.
E- Yog Nindra, Pranayama and Vipasna ate other
Indian methods.
Fr Biofeedback.
Biofeedback
Biofeedback (introduced for the rst time in 1969) is
the use of an instrument (usually electronic), which
provides immediate feedback to the patient regarding
his physiological activities normally not available to
the conscious mind, such as ECG, EEG, pulse rate,
blood pressure, EMG, and galvanic skin response
(GSR).
The feedback helps the patient, apparently to con-
trol these responses. Relaxation is easily achieved by
this method. A simpler form (relaxometer) uses only
one parameter, the GSR.
The other uses of biofeedback include treatment
of enuresis, migraine headaches, tension headache,
idiopathic hypertension, incontinence, cardiac archyth-
‘mias, uncontrolled generalised tontc clonic seizures,
and also for neuromuscular rehabilita
Rehabilitation
Psychiatric rehabilitation is debned as restoration of
the fullest physical, mental, social, vocational, and
economic usefulness of which the person suffering
from psychiatric disorder is capable.
hological Treatment
SS GD
A large number of patients with psyehiar
ders (such as schizophrenia) may have.»
Of Ife, residual symptoms, and |
mptoms, and long-term disabili
Although eatly recognition and treatment isthe corner
Stone of preventing long: te
rm disability, a sub
‘number of patients may need rehabilitation
There are several components and methods aval
able for rehabilitation, depending om the type andor
stage of disorder and the type of support available
(0 the patient. Necessarily, a comprehensive a
ment is needed before deciding on the individualized
fehabilitation for a particular patient.
Some of the methods used for psychiatric reba
bilitation include housing placement (such as half
way homes, supervised housing), vocational training
and rehabilitation (such as activity therapy. sheltered
workshop, transitional or supported employment.
vocational guidance, occupational therapy), and treat-
ment (such as ensuring compliance with medication,
social skills therapy. family therapy, cognitive reme-
diation)..
‘There is an acute shortage of psychiatric rehabili-
isabilities (Equal Opportunities, Protection of
Rights, and Full Participation) Act (PDA), 1995 is a
step forward, as it includes psychiatric disorders and
‘mental retardation,
Indian Perspective
Just about the time Freud was practicing psycho-
analysis, Girindra Shekhar Bose was using his own
version of psychoanalysis in Calcutta. However,
currently psychoanalysis is not widely used in India.
Itis believed by some that most Indian patients,
as compared to patients in western, developed coun-
tries, are not psychologically minded and are unable
to introspect. They lack verbal Buency and have more
physical symptoms,
The Indian patients have difficulty in main-
taining one-to-one relationship with the physician-
psychiatrist, as they believe him to be a healer who is
of higher status than them (something like a Guru).
‘The Guru-Chela relationship in the patient-doctor
interaction was best described by JS Neki. = Poctsenatyss (which veids giving direct
is Giffouk es patients expect the therapist to
guide them and make decisions for them. The gatieas
are also often fatalistic (‘this kad to keppen’ “i is
the result of destiny end pas karme") end often eve
magical expectations of core.
‘Most psychotheresins in Indie exes that West-
em models of psychetherepy cannot be directly
vensplemed in the Indien seine Peychothecegy in 2
is yes
active role. Honever, in poychologically mint
etocated Indien patienss. western eovsiels ozs toe
with or withoot modibcation.
The commonest type of peychaberepy we
India is probably supportive prycborbere
use of CBT hes increased wobanticlly ove
fen years
