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Monday, May 19, 2008

Supportive Psychotherapy mostly Novice Pilots Flying In The Dark Without Maps

Supportive therapy in psychiatry is mostly done by unexperienced psychiatric residents during their training. Most residents as well as psychiatrists think that supportive therapy is just providing a sense of safety, support self esteem and hope, alternated by advice how patients should live their life, structure their day, get to work and behave. Psychiatrist the least qualified usually apply for the supervision of residents doing these therapies based on these premises.

To my opinion these kind of therapies are the hardest to do, need the most experienced and psychotherapeutic best qualified psychiatrists. Yes psychiatrists because this kind of therapy is mostly done with the most vulnerable patients with sever psychopathology and usually with several diagnoses. Sure residents can be trained in supportive therapy and they should be.

What makes supportive psychotherapy besides the patients in need for it so difficult?

  • It is not just common sense, interpersonal skills, and a capacity for empathy.To my opinion it is a psychotherapy as dimension of dynamic psychotherapy, to a greater or lesser extent depending on the particular context, problems, and needs of the person. Interpretive approaches and transference work must also be used with the so-called less suitable patients who have a history of immature object relations in this kind of treatment. But it has to be used wisely.

  • Supportive psychotherapy relies heavily on psychoanalysis in describing characteristic techniques, such as “improving ego functions,” “minimizing the focus on transferential material,” and “confronting maladaptive defenses,” thus assuming some familiarity with ego-psychological psychodynamic theory. For beginning psychotherapists it can hardly be expected to understand what it means to “manage” or “manipulate” the transference in supportive therapy and how this differs from “interpreting” the transference in a more exploratory treatment, let alone which patients under what circumstances require such “management” and why.

  • Without a good working hypotheses about the unconscious motives, feelings,
    and conflicts underlying a person’s distress, it is also difficult to see how they would have any basis for predicting what would be supportive or nonsupportive for the individual patient at any given moment in the treatment.

  • You also need to understand the differences between thinking psychoanalytically in providing support and acting like a psychoanalyst.One of the most important rules is: “Do not say everything you know, only what will be helpful.”

  • The supportive therapist helps the patient see things more clearly by supporting
    reality testing, tactfully challenging unrealistic ideas, and demonstrating more effective, less costly ways of defending while supporting adaptive have to understand these different aspects in your patient before you can even work on it.

  • The main priority in supportive psychotherapy is to build a “holding environment”
    and to foster the therapeutic alliance. This is hard to dose, most unexperienced therapist remain to silent, distant.

  • It is hard to know about how responsive and self-revealing you should be, about what, and why. The best way to learn this is in supervision. Supervisors should feel free to share their own learning process, including any gaffes, confusion, and embarrassing moments they may have experienced along the way.

  • You should realize that small improvements can lead to bigger changes and that setting overly ambitious goals will only increase the likelihood of failure. Doing “just enough” is good enough—just enough to reduce anxiety,build self-esteem, instill hope, support deficient psychological functions, and improve overall functioning.

The biggest problem with this effective and satisfying kind of treatment is the lack of a clear definition, consensus about training and guidelines for supportive therapy.

This post is based on Teaching Supportive Psychotherapy to Psychiatric Residents by Carolyn J. Douglas, M.D. and published in the American Journal of Psychiatry 165:4, April 2008, but holds the views of the author of this post: Dr Shock
By the way it is an excellent account of supportive therapy


shraddha said...

Great post!
It kinda reminds me of "In treatment" .This series that come on HBO.If it does not come at your place, check out the website.Its awsome!

Joseph j7uy5 said...

The term "supportive psychotherapy" seems to be used in two different ways. There is the formal meaning, which describes a well-developed techincal art; and the informal, but more common meaning, which refers to a well-intentioned, well-informed, but basically unstructured interaction with vague therapeutic intent.

It is the unfortunate destiny of all psychiatric terms: they eventually become diluted by misuse, to the point that they become meaningless.

Dr. Shock said...

As a psychiatrist only the formal method will do and that is what we will need to educate.
Thanks and regards Dr Shock