August 2013  << Back  

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Learning Supportive Psychotherapy: An Illustrated Guide

Richard Balon, MD

Wayne State University, Detroit, MI, USA

By Arnold Winston, Richard N. Rosenthal, and Henry Pinsker. Arlington, VA: American Psychiatric Publishing, Inc.; 2012; ISBN 978-1-585-623990; pp 211; $72 (paperback; DVD included).

Supportive therapy is probably the most practiced psychotherapy among psychiatrists, or at least the kind of psychotherapy modality most psychiatrists assume they practice. I write this because, as the authors of this book write, “supportive psychotherapy is a treatment approach that shares tactics and objectives with the medical management that is familiar to physicians who are entering the specialty of psychiatry” (p 1). Most psychiatrists do not have time to practice psychodynamic psychotherapy or cognitive-behavioral therapy (or may not get reimbursed for these psychotherapies) and may practice some mixture of psychotherapeutic techniques they consider to be supportive psychotherapy. Whether it is a true practice of supportive psychotherapy is a different question. The authors of this volume point out that, “The term supportive therapy is frequently used in nonpsychiatric studies to denote the designation for an approach that involves expression of interest, attention to concrete services, encouragement and optimism. This is a supportive relationship or supportive contact, but not supportive psychotherapy. Supportive psychotherapy is based on diagnostic evaluation; the therapist’s actions are deliberate and designed to achieve specified objectives. …In the psychiatric literature, the terms supportive therapy and supportive psychotherapy have been used interchangeably. This is unfortunate, because the nonspecific support provided to patients who have medical or surgical problems is also characterized as ‘supportive therapy,’ in this case referring to efforts that make the patient more comfortable but do not remediate the underlying problem. We will always use the long form—supportive psychotherapy—to emphasize that we are writing about a professional service that is provided in a mental health context by a person trained in mental health theory and practice. We define supportive psychotherapy as a dyadic treatment that uses direct measures 1) to ameliorate symptoms and 2) to maintain, restore, or improve self-esteem, ego function, and adaptive skills” (p 8-9).

The authors write that self-esteem involves the patient’s sense of efficacy, confidence, hope, and self-regard. Ego functions include relation to reality, thinking, defense formation, regulation of affect, synthetic function, and others. Finally, they define adaptive skills as actions associated with effective functioning (also stating that the boundary between ego functions and adaptive skills is not sharply defined).

I have delved into the definition of supportive psychotherapy because I have heard many colleagues and trainees say they practice supportive psychotherapy. However, when I asked what the goals of supportive psychotherapy were, I rarely received an answer close to what the authors of this book describe as goals (ie, amelioration of symptoms, maintaining and supporting ego functions). Thus, there seems to be a wide misconception either in perception or in education of what supportive psychotherapy is. This volume certainly is trying to remediate it and help psychiatrists and others learn what supportive psychotherapy really is and how to practice it.

The book consists of 9 chapters: 1. The concept of supportive psychotherapy; 2. Principles and mode of action; 3. Assessment, case formulation, and goal setting (including a vignette on assessment); 4. Techniques (including 2 vignettes: severe, persistent mental illness in an uncooperative patient and supportive-expressive treatment); 5. General framework of supportive psychotherapy; 6. The therapeutic relationship (including a vignette addressing a misalliance); 7. Crisis intervention (including a vignette on crisis intervention); 8. Applicability to special populations (including a vignette on substance use disorder); and 9. Evaluating competence and outcome research. The accompanying DVD (which is almost 86 minutes long) includes vignettes mentioned in the text, featuring patients with therapists and accompanying comments. The DVD is a great addition for any clinician beginning to practice psychotherapy, because it has been more uncommon for trainees to be able to see real psychotherapy sessions.

The first chapter provides most of the definitions and terminology I already mentioned. The authors make defining supportive psychotherapy a bit fuzzy. Unfortunately, instead of sticking to what supportive psychotherapy is, they get into too much of what supportive psychotherapy isn’t and contrasting it with psychodynamic psychotherapy. The second chapter discusses the underlying assumptions about supportive psychotherapy, emphasizing that “Supportive psychotherapy is conducted in conversational style, involving examination of the patient’s current and past experiences, responses, and feelings. Although the initial focus is on self-esteem, ego function, and adaptive skills, the therapeutic alliance may be the most important element of the therapy” (p 32). The third chapter reviews assessment, case formulation and goal setting. The goal setting should be organized as follows: 1) amelioration of symptoms, 2) improvement of adaptation, 3) enhancement of self-esteem, and 4) improvement of overall functioning.

The fourth chapter focuses on techniques of supportive psychotherapy: alliance building (expression of interest, expression of empathy, expression of understanding, sustaining comments, conversational style, repair of misalliance); esteem building (praise, reassurance, normalizing, universalizing, encouragement, exhortation); skills building and adaptive behavior (advice, teaching, modeling adaptive behavior, anticipatory guidance); reducing and preventing anxiety (conversational style, sharing the agenda, verbal “padding,” naming the problem, normalizing, reframing, rationalizing); and awareness expanding (clarification, confrontation, interpretation).

The following chapter goes over some practical issues, such as indications and contraindications of supportive psychotherapy; initiation of treatment and office arrangement; initiation and termination of sessions; timing and intensity of treatment sessions; and professional boundaries. The indication and contraindication lists are important. Contraindications include “1) predominance of primitive defenses (eg, projection and denial); 2) absence of capacity for mutuality and reciprocity, exemplifying and impairment in object relations; 3) inability to introspect; 4) inadequate affect regulation, especially in the form of aggression; 6) somatoform problems; and 7) overwhelming anxiety related to issues of separation or individuation” (p 91). More specifically, indications conceptually fall into 2 groups: crisis, which includes acute illnesses that emerge when the patient’s defenses are overwhelmed in the context of intense physical or psychological stress (acute crisis, adjustment disorder in relatively well-compensated people, medical illness, substance use disorders [SUDs], alexithymia), and chronic illness with concomitant impairment of adaptive skills and psychological functions. Supportive psychotherapy is contraindicated when psychotherapy itself is contraindicated (eg, in delirium and other organic mental disorders, in help-rejecting complainers, in con artists and malingerers, and in psychopathic individuals) (p 95). This chapter also emphasizes that a formal termination process is not part of supportive psychotherapy; it ends when goals have been reached or when the patient elects to not continue treatment. Chapter 6 focuses on the therapeutic relationship and delves into issues such as transference, therapeutic alliance, misalliance (recognition and repair), resistance, and countertransference. The chapter emphasizes that a robust therapeutic alliance is a strong predictor of positive outcome in psychotherapy (p 122).

The chapter on crisis intervention brings to the reader’s attention that crisis states can lead to personal growth rather than physical and psychological deterioration. It provides specific examples of crisis intervention, including in the area of suicide. The following chapter reviews the applicability of supportive psychotherapy to special populations, such as those with severe mental illness, personality disorders, SUDs, and co-occurring mental illness and SUDs. The role of psychoeducation for patients and family members in all areas is emphasized. The last chapter discusses psychotherapy supervision and methods of assessment of trainees’ competence in supportive psychotherapy. The part on outcome research is mostly non-contributory.

In spite of some mentioned fuzziness in definition discussion (in terms of what this modality isn’t) and a bit much rehashing of psychodynamic issues, this is a useful book. The novice can certainly learn a lot (also by observing the sessions on the enclosed DVD) about what supportive psychotherapy really is and how to practice it. The volume also will be useful to psychotherapy trainers in residency programs and to physicians supervising therapists conducting supportive psychotherapy in the severely mentally ill and/or in patients with SUDs. The vignettes (transcribed and on DVD) are an especially helpful part of the book.