Abstract
Aim:
The aim of this article is to describe the principles of supportive psychotherapy.
Conclusion:
The author illustrates the principles of supportive psychotherapy with a case vignette.
Supportive psychotherapy is an important clinical skill for all psychiatrists.
Keywords
The principles of supportive psychotherapy form part of the foundations of the doctor-patient relationship in medical practice, and of all psychotherapies. As a specific form of psychotherapy, it is useful for two groups of patients:
1
A previously well-functioning person psychologically destabilised by one or more life events, typically involving loss, e.g. betrayal in a relationship, divorce, illness in oneself or other, bereavement. Therapy aims at restitution of the psychological status quo ante, if that’s all the patient wants. Patients with a chronic or recurrent disability, e.g. chronic physical illness often with associated pain and/or handicap (e.g. rheumatoid arthritis, multiple sclerosis), or a chronic form of mental illness, including personality disorder. Supportive psychotherapy aims to minimise deterioration and maximise competence within the limitations imposed by the illness, the patient’s personality and circumstances, and the treating system’s resources. It may be combined with psychoeducation or psychotropic medication.
Supportive psychotherapy has a specific meaning derived from psychoanalysis, which describes the therapist’s support for the patient’s adaptive or more mature personality defences. Thus, a degree of denial may remain unchallenged in the psychotherapy of a seriously ill medical patient if it enables him to persevere with a potentially life-saving treatment. Similarly, a patient with a borderline personality disorder who is about to sit an exam may be allowed to rationalise that exam stress caused him to forget his girlfriend’s birthday, rather than exploring the possibility that such forgetting may be an expression of his resentment. Some forms of interpretation offered by a therapist in psychodynamic therapy closely resemble the empathic summary of a patient’s distress provided by a therapist in supportive psychotherapy. 2
Techniques
Contrary to a popular misconception, supportive psychotherapy requires more than the doctor listening sympathetically to the patient for a few minutes or expressing concern for the patient’s plight.
Emotionally attuned listening: the doctor listens to the patient’s story, the feelings the patient expresses and non-verbally communicates, and the doctor’s own ‘gut’ responses. The unsaid is also important; thus, a medically ill patient who complains endlessly about treatment may be avoiding the frightening question ‘am I going to die?’
An empathic paraphrase of what the patient said and the doctor’s understanding of the patient. Thus, to a paranoid patient who prevaricates and asks many questions about a proposed medication, the psychiatrist may say:
‘From what you tell me, John, people have always let you down, so you try to be strong and not depend on anybody. I think you’re worried these tablets might make you weak. Maybe that’s why you don’t trust me or the tablets?’
Clarification and explanation of the nature of the patient’s difficulties and how they may be investigated and helped.
Reassurance and encouragement: This is not false optimism, but is reality based. So, with the aforementioned patient: ‘John, I believe this medication will help calm your stress. Could you agree to try it? I’ll be here, because I want to know if it’s helping and not making you weak. If you try it but don’t like it, you can tell me, and I will try to change it.’
Advice
The psychiatrist’s advice is based on professional knowledge, e.g. medication effects, the usefulness of a support group or of taking time off work. In other matters, referral to a service that deals with specific concerns is appropriate.
Generally, the psychiatrist avoids giving advice, but instead explores the patient’s difficulty in making a decision. Typically, this reflects interpersonal problems or the anticipated consequences of change. Reminding the patient of how he went about achieving a recent success may also challenge helplessness.
Spouse and family
They are often a resource for the patient. They also have their own distress which may also affect the patient, and for which they may require supportive psychotherapy in a couple, family or group mode. This may be combined with specific further interventions, e.g. family psychoeducation, hospitalising the patient, or psychotherapy for a family member.
Case example
Fred B is a 38-year-old, recently married farmer from rural Victoria, with a history of chronic kidney disease, currently hospitalised for his third kidney transplant operation. The previous two grafts failed. The renal unit requested an urgent psychiatric consultation following a ‘code grey’ alert when Fred became agitated, verbally aggressive, threatened to pull out his intravenous (i/v) and dialysis lines and to leave hospital.
After introducing myself and other members of the psychiatry consultation-liaison team:
Your kidney doctors asked us to see you because they’re worried that you got upset. Could you tell us what’s happening for you?
(silent, sullen, eyes downcast, slumped in his chair; he remains silent).
I wonder what might have upset you? (Silence.)
It’s the third time, this is the third time.
It’s the third time you’ve had a kidney transplant? (FB nods, but doesn’t raise his head). And it’s too much for you? It’s more than you expected?
I’ve been in three times, January 2008, July 2011, and now (the clinical impression is clearly not one of delirium or steroid- induced agitation).
You’re right. Nowadays, kidney transplants aren’t meant to be so hard. You were sick for so long, then
My wife worries a lot too; she’s all by herself in W…
So you’re in hospital, far from home, worrying why the transplants aren’t working; you also worry about your wife, you’ve just started your future together, and I guess you don’t want to show her that you’re worried (he nods). That’s a lot for you to carry all by yourself! (Silence.)
I also wanted to go to the funeral.
Which funeral?
Bill, a friend.
Bill was important to you?
He was like my second dad. He gave me my first job, and helped me out with money when the farm wasn’t going right.
Could you tell us what happened to Bill?
He was sick for a long time, lung cancer (cries).
That’s a cruel disease (silence). Did you know he was dying?
I saw him in January, but I didn’t get to see him again; I rang a couple of times but he couldn’t talk; then I got crook, and I couldn’t go to the funeral last week.
So you didn’t get to say goodbye to Bill? (nods). And his family – do they know you’re crook?
(nods, talks of his close relationship with Bill’s family).
So you’re very sad about Bill, a special friend, but you didn’t get to say goodbye, and you couldn’t help (Bill’s wife) in her sadness,
(sitting forward in the chair, making eye contact with me for the first time, his voice trembles but is clear):
I felt I was going to explode. I just wanted to leave, it’s not the staff’s fault, but I was just so … so …(hesitates.)
So? …
Angry. I know it was wrong.
Well, you care about people, Fred, and you try to be fair, so maybe getting angry isn’t easy for you (pause; Fred is looking intently at me). And with whom could you be angry? The staff just try to help, you knew that, but you felt so scared and worried; but you couldn’t
That’s exactly right. (He sits back in the chair, appears relieved and calm.) I’m sorry, doc. (He looks directly at me as if he is waiting to see if I will accept his apology.)
Fred, I think you’re the kind of man who wants to
Fred, I appreciate you telling us about your worries and the anger; I hope you feel I’ve understood? (He nods.) We can talk again on Friday. If it’s OK with you, we’ll explain your worries to the nurses, so you can talk to them if those worries build up again inside you. People find that often happens when they’re stuck in hospital, especially at night. My colleague, Dr A (the psychiatry registrar), will drop in to see you tomorrow. And we should meet your wife when she’s here to see how she’s coping. Also, I think you or your wife may have questions that your kidney doctors could help answer, so we can talk about that too.
Thank you, doctor (he shakes my hand warmly).
This case has been de-identified.
Footnotes
Disclosure
The author reports no conflict of interest. The author alone is responsible for the content and writing of the paper.