Psychotherapy & Behaviour Therapy
Psychiatry · Anxiety · lean revision notes
Psychotherapy & Behaviour Therapy
Psychotherapy is the systematic, evidence-based use of psychological techniques to treat mental disorders and maladaptive behaviour. For NEET PG the single most rewarding skill is matching a specific technique to the disorder/scenario — the learning principle behind it, its named originator, and its mechanism.
Overview & Classification
Psychotherapies are broadly grouped by their underlying theory of how behaviour and distress arise.
| Therapy family | Core theory | Representative techniques | Key names |
|---|---|---|---|
| Behaviour therapy | Maladaptive behaviour is learned (conditioning) and can be unlearned | Systematic desensitisation, flooding, aversion, exposure & response prevention, token economy | Wolpe, Skinner, Pavlov |
| Cognitive / CBT | Distorted thoughts drive emotion & behaviour | Cognitive restructuring, thought records, behavioural activation | Aaron Beck, Albert Ellis (REBT) |
| Psychoanalytic / psychodynamic | Unconscious conflicts & early experience | Free association, dream analysis, interpretation of transference | Sigmund Freud |
| Humanistic / supportive | Self-actualisation, unconditional positive regard | Client-centred therapy, reassurance, ventilation | Carl Rogers |
| Third-wave / others | Acceptance, mindfulness, dialectics | DBT, ACT, mindfulness-based cognitive therapy | Marsha Linehan (DBT) |
High-yield: Behaviour therapy is based on learning theory (no insight required); psychoanalysis is based on insight into unconscious conflict. This conceptual split is the most commonly tested single-best-answer distinction.
Learning Principles — the Foundation
Classical conditioning (Pavlov)
An originally neutral stimulus is paired with an unconditioned stimulus until it elicits the response on its own.
UCS (food) → UCR (salivation), then NS (bell) + UCS → UCR, finally CS (bell) → CR (salivation).
- Acquisition → extinction (CS no longer paired) → spontaneous recovery.
- Clinical relevance: phobias, conditioned nausea in chemotherapy, Little Albert experiment (Watson — fear conditioning).
Operant conditioning (Skinner)
Behaviour is shaped by its consequences. The four contingencies are the classic table.
| Add stimulus | Remove stimulus | |
|---|---|---|
| Increases behaviour | Positive reinforcement (reward) | Negative reinforcement (remove aversive) |
| Decreases behaviour | Positive punishment (add aversive) | Negative punishment / response cost (remove reward) |
High-yield: Negative reinforcement increases behaviour (by removing something unpleasant) — students confuse it with punishment. Taking an analgesic to stop pain is negative reinforcement.
- Shaping = reinforcing successive approximations.
- Schedules: variable-ratio reinforcement produces the most persistent, extinction-resistant behaviour (basis of gambling addiction).
- Premack principle: a high-frequency behaviour reinforces a low-frequency one ("eat your vegetables, then dessert").
Behaviour Therapy Techniques
Systematic desensitisation (Joseph Wolpe)
The flagship treatment for specific phobia and the most asked technique.
Steps (flow):
- Train deep muscle (Jacobson) relaxation.
- Construct an anxiety hierarchy (least → most feared situations).
- Pair relaxation with graded, imagined or real exposure, ascending the hierarchy only when the previous step evokes no anxiety.
- Mechanism: reciprocal inhibition — relaxation and anxiety are physiologically incompatible; you cannot be relaxed and anxious simultaneously.
- Graded and gradual are the keywords. Counterconditioning of the phobic stimulus.
High-yield: Systematic desensitisation = relaxation + graded hierarchy + reciprocal inhibition (Wolpe). If the stem says "gradual exposure starting from least feared," the answer is systematic desensitisation.
Flooding & implosion
Direct, ungraded exposure to the most feared stimulus, in vivo (flooding) or in imagination (implosion), without escape, continued until anxiety extinguishes.
- No hierarchy, no relaxation — opposite of desensitisation.
- Mechanism: extinction of the conditioned fear response; the feared catastrophe does not occur.
Exposure and response prevention (ERP)
Treatment of choice (behavioural) for OCD. The patient is exposed to the trigger (e.g., touching a doorknob) and prevented from performing the compulsion (hand-washing) until anxiety subsides on its own. Breaks the obsession–compulsion reinforcement cycle.
Aversion therapy
Pairs an undesirable behaviour with an unpleasant (aversive) stimulus so the behaviour becomes associated with discomfort (classical conditioning).
- Disulfiram for alcohol dependence (aldehyde-dehydrogenase block → acetaldehyde build-up → flushing, nausea) is the prototype.
- Apomorphine, electric shock, covert sensitisation (imagined aversive imagery).
- Historically used (controversially) for paraphilias and alcohol use disorder.
Token economy
Operant programme: desirable behaviours earn tokens (secondary reinforcers) exchangeable for privileges/rewards.
- Used in chronic schizophrenia, institutionalised/intellectual-disability settings, and de-addiction wards (contingency management).
Other behavioural methods
| Technique | Principle | Typical use |
|---|---|---|
| Biofeedback | Operant control of autonomic functions via real-time signal | Tension headache, hypertension, anxiety |
| Assertiveness training | Social skills + reciprocal inhibition | Social anxiety, passivity |
| Modelling (Bandura) | Observational/vicarious learning | Phobias, social skills in children |
| Contingency management | Reinforcement of abstinence | Substance use disorders |
| Habit reversal | Awareness + competing response | Tics, trichotillomania |
| Sensate focus (Masters & Johnson) | Graded non-demand touching | Sexual dysfunction |
Cognitive Behaviour Therapy (CBT)
Developed by Aaron Beck. The cognitive triad of depression — negative views of the self, world, and future — is a perennial exam fact.
Beck's cognitive model (flow): Situation → Automatic negative thought → Emotion → Behaviour → (reinforces the thought).
Cognitive distortions (test these by example)
- All-or-none (dichotomous) thinking
- Overgeneralisation
- Catastrophising
- Selective abstraction / mental filter
- Personalisation
- Arbitrary inference / jumping to conclusions
- Magnification & minimisation
Core CBT components
| Component | What it does |
|---|---|
| Cognitive restructuring | Identify, challenge & replace distorted automatic thoughts |
| Thought record (dysfunctional thought diary) | Log situation–thought–emotion–evidence-for/against–balanced thought |
| Behavioural activation | Schedule pleasurable/mastery activities to break the withdrawal–low-mood cycle in depression |
| Socratic questioning / guided discovery | Therapist helps patient examine evidence rather than telling them |
| Behavioural experiments | Test the validity of a belief in real life |
| Homework | Structured between-session tasks |
High-yield: CBT is the psychotherapy of choice (often first-line) for mild–moderate depression, panic disorder, generalised anxiety, PTSD, OCD (with ERP), bulimia nervosa, and insomnia (CBT-I). It is structured, present-focused, time-limited, and collaborative.
High-yield: Behavioural activation is the key CBT element for depression; exposure is the key element for anxiety/phobia/OCD.
Rational Emotive Behaviour Therapy (REBT) — Albert Ellis
The ABC model: Activating event → Belief (irrational) → Consequence (emotional). Therapy adds D (disputing the belief) and E (effective new philosophy). Confronts irrational beliefs more directly/forcefully than Beck's CBT.
Dialectical Behaviour Therapy (DBT) — Marsha Linehan
The treatment of choice for borderline personality disorder and recurrent self-harm/parasuicidal behaviour.
- Combines CBT with mindfulness and acceptance; balances change with acceptance (the "dialectic").
- Four skill modules: Mindfulness, Distress tolerance, Emotion regulation, Interpersonal effectiveness (mnemonic "Make Domestic Emotions Improve").
Other "third-wave" therapies
- ACT (Acceptance & Commitment Therapy) — psychological flexibility, values-based action.
- MBCT (Mindfulness-Based Cognitive Therapy) — prevents relapse of recurrent depression.
- IPT (Interpersonal Therapy) — time-limited, focuses on grief, role transitions, role disputes, interpersonal deficits; strong evidence in depression.
Psychoanalytic / Psychodynamic Therapy (Freud)
Aims to make the unconscious conscious and resolve early conflicts through insight.
Techniques:
- Free association — saying whatever comes to mind uncensored.
- Dream analysis — manifest vs latent content; "the royal road to the unconscious."
- Interpretation of resistance and transference.
Structural model: Id (pleasure principle) — Ego (reality principle) — Superego (conscience/morality).
Transference vs countertransference
| Term | Definition |
|---|---|
| Transference | Patient redirects feelings about a significant past figure onto the therapist |
| Countertransference | The therapist's emotional reaction (conscious/unconscious) toward the patient |
Defence mechanisms (very high-yield)
| Maturity | Mechanism | One-line cue |
|---|---|---|
| Mature | Sublimation | Channel impulse into socially useful act (aggression → surgeon) |
| Mature | Humour, altruism, suppression | Conscious postponement = suppression |
| Neurotic | Repression | Unconscious exclusion from awareness |
| Neurotic | Reaction formation | Behave opposite to true feeling |
| Neurotic | Displacement | Shift emotion to a safer target (kicks the dog) |
| Neurotic | Isolation of affect, intellectualisation, rationalisation, undoing | Common in OCD |
| Immature | Projection | Attribute own impulses to others (paranoia) |
| Immature | Denial, regression, acting out, somatisation | — |
| Immature | Splitting | All-good / all-bad — typical of borderline PD |
High-yield: Suppression = conscious; Repression = unconscious. Splitting → borderline. Projection → paranoid. Sublimation is the only "mature/healthy" defence frequently asked.
Mnemonic — Beck's cognitive triad: "Me, my World, my Future" are all seen negatively in depression.
Choosing the Therapy — Disorder Matching
Quick matching table (the highest-yield section for MCQs):
| Condition | Best-fit psychotherapy |
|---|---|
| Specific phobia | Systematic desensitisation |
| OCD | Exposure & response prevention (ERP) |
| Panic disorder / GAD | CBT |
| PTSD | Trauma-focused CBT, EMDR |
| Depression (mild–moderate) | CBT / IPT / behavioural activation |
| Borderline PD / self-harm | DBT |
| Alcohol dependence | Aversion (disulfiram), motivational interviewing, contingency management |
| Bulimia nervosa | CBT (first-line) |
| Chronic schizophrenia (ward behaviour) | Token economy |
| Sexual dysfunction | Sensate focus (Masters & Johnson) |
| Enuresis (child) | Bell-and-pad (classical conditioning) |
Complications, Limitations & Contraindications
- Flooding can precipitate intense anxiety or panic; avoid in patients with cardiac disease or fragile coping.
- Aversion therapy raises ethical concerns and has high relapse rates if used alone.
- Psychoanalysis is long, costly, and unsuitable for acute psychosis, low ego-strength, or poor verbal/insight capacity.
- Insight-oriented therapy can transiently worsen anxiety; supportive therapy is safer for crisis and low-functioning patients.
- All psychotherapies require capacity for engagement; active psychosis, severe agitation, or intoxication must be stabilised (often pharmacologically) first.
Key Differentials / Look-alike Distinctions
- Systematic desensitisation vs flooding: graded + relaxation vs ungraded + no relaxation.
- Positive vs negative reinforcement: both increase behaviour; punishment decreases it.
- Negative reinforcement vs negative punishment: reinforcement removes an aversive (behaviour ↑); punishment removes a reward (behaviour ↓).
- Transference vs countertransference: patient→therapist vs therapist→patient.
- Repression vs suppression: unconscious vs conscious.
- CBT vs psychoanalysis: present, structured, thoughts/learning vs past, unstructured, unconscious/insight.
Recently asked / exam angle
NEET PG and INI-CET have repeatedly tested:
- "Graded exposure with relaxation training" → systematic desensitisation (Wolpe); mechanism = reciprocal inhibition.
- Treatment of choice for OCD behaviourally → ERP.
- Therapy of choice for borderline personality disorder → DBT (Linehan).
- "All-good or all-bad view of others" → splitting; "attributing own feelings to others" → projection.
- Token economy as operant conditioning used in chronic schizophrenia / intellectual disability.
- Disulfiram as aversion therapy; negative reinforcement identification in a clinical vignette.
- Beck's cognitive triad and identifying cognitive distortions from a quoted patient statement.
- Variable-ratio schedule → most resistant to extinction (gambling).
- Bell-and-pad for nocturnal enuresis → classical conditioning.
Rapid revision
- Behaviour therapy = learning theory; psychoanalysis = insight.
- Systematic desensitisation (Wolpe): relaxation + graded hierarchy → reciprocal inhibition; best for phobia.
- Flooding = ungraded maximal exposure → extinction; no relaxation, no hierarchy.
- ERP = behavioural treatment of choice for OCD.
- Negative reinforcement INCREASES behaviour by removing an aversive stimulus.
- Variable-ratio schedule is most resistant to extinction.
- Aversion therapy prototype = disulfiram for alcohol dependence.
- Token economy = operant; chronic schizophrenia / intellectual disability.
- Beck's cognitive triad = negative self, world, future; behavioural activation is core for depression.
- DBT (Linehan) = borderline PD; modules — mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness.
- Splitting → borderline; projection → paranoid; sublimation = only mature defence.
- Repression = unconscious; suppression = conscious; transference = patient→therapist.