pSYCHIATRY

5 keys to good results with supportive

Evidence-based technique gains new respect as a valuable clinical tool

upportive psychotherapy began as a® second-classDowden Health Media treatment whose only operating principle was S“being friendly” with the patient (Box, page 28).1 Critics called it “simple-minded”Copyright2 andFor sniffed, personal “if it is use only supportive, it is not therapy…if it is therapy, it is not supportive.”3 Since its lowly beginning, however, supportive psychotherapy has been proven highly effective, and clinicians have developed operating principles that distinguish it from expressive psychotherapy (Table 1, page 31).4 To help you make good use of supportive psycho-

therapy, this article describes its evolution and: WELLS

• evidence that demonstrates its effectiveness LEIGH • 5 key components for clinical practice © 2007 • how to use it when treating challenging patients. John Battaglia, MD Medical director Program of Assertive Community Treatment A proven treatment Clinical associate professor Eff ective long-term therapy. Much research on sup- Department of psychiatry portive psychotherapy comes from studies in which University of Wisconsin Medical School Madison, WI supportive psychotherapy was included as a “treatment as usual” comparison. In an extensive longitudinal study, for example, the Meninger Psychotherapy Re- search Project examined 42 patients receiving psycho- analysis, psychodynamic psychotherapy, or supportive psychotherapy over 25 years.5 Despite the institutional expertise in and expressive psychotherapy, patients in supportive psychotherapy did just as well as those receiving the Current Psychiatry other treatments. Researchers found that each therapy Vol. 6, No. 6 27

For mass reproduction, content licensing and permissions contact Dowden Health Media. Box used supportive psychotherapy simply en- A supportive approach couraged patients to ventilate their feelings may work when expressive and discuss problems. Supportive thera- psychotherapy fails pists were instructed to be nondirective and avoid confrontation unless the patient arly psychotherapy consisted of proposed it. Edirective methods by which Charcot, Both therapies combined with imipra- Supportive Freud, and others “suggested” that patients mine produced similar rates of moderate psychotherapy rid themselves of symptoms while under to marked improvement in patients with hypnotic trance. Benefi cial effects were agoraphobia (85% to 100% with supportive sometimes immediate and dramatic but therapy, 76% to 100% with behavior thera- rarely lasted. py). For patients with mixed phobias, 71% Dissatisfi ed with directive techniques, to 100% improved moderately or markedly clinicians developed psychoanalytic with supportive therapy compared with principles and expressive psychotherapy, which emphasizes analyzing 88% to 100% with behavior therapy. Among patients with simple phobia, 72% to 86% Clinical Point and uncovering unconscious thoughts, feelings, and motivations. Although experienced moderate to marked improve- A conversational expressive psychotherapy became ment with supportive therapy, compared style allows greater popular, many patients—especially those with 87% to 93% with behavior therapy. with severe mental illness—were deemed spontaneity and unsuitable candidates or failed to improve. Improving personality disorders. Sever- creativity in solving These patients were relegated to al studies examined a form of supportive problems supportive interventions, which initially psychotherapy that used a manualized, were vaguely defi ned methods to reduce structured protocol for treating higher anxiety and provide encouragement. functioning patients who traditionally Therapists required little or no specialized have been treated with expressive psy- training to provide supportive therapy and did not expect patients to make character chotherapy. The protocol used a conver- (or structural) change. Surprisingly, sation-based, dyadic style to improve many patients improved despite vague self-esteem and adaptive skills through therapeutic guidelines. data-based praise, advice, education, ap-

Source: Reference 1 propriate reassurance, anticipatory guid- ance, clarification, and confrontation. carried more supportive elements than Under these reproducible conditions, was intended, and supportive elements ac- supportive psychotherapy showed good counted for many of the observed changes. efficacy compared with dynamic thera- They concluded that: pies for patients with depressive, anxi- • thinking of change in terms of “struc- ety, and personality disorders. tural” vs “behavioral” was not useful A review of studies from 1986 to 1992 • change did not occur in proportion to found that supportive psychotherapy was resolving unconscious confl ict. effective for a variety of psychiatric and medical conditions, including schizophre- Combating phobias. A study of behavior nia, , depression, posttrau- therapy for treating phobias had similar matic stress disorder, anxiety disorders, results.6 Patients with agoraphobia, mixed personality disorders, substance abuse, and phobia, or simple phobias were treated stress associated with breast cancer and with behavior therapy alone, behavior back pain.9 therapy plus imipramine, or supportive psychotherapy plus imipramine for 26 CASE STUDY weekly sessions. A negative experience Therapists in the behavior therapy group Mrs. S, a 32-year-old grant writer, is referred to used a manualized, highly structured treat- a psychiatrist by an emergency department ment protocol that included in vivo desen- physician after she cut herself following an Current Psychiatry 28 June 2007 sitization and homework. Therapists who argument with her husband. She has chronic continued on page 31 continued from page 28 Table 1 Diff erences between expressive and supportive psychotherapy BROKEN Expressive Supportive Component psychotherapy psychotherapy Treatment goal Insight Reduce symptoms PROMISES Therapist style Opaque Conversational (“real”)

Transference Examine Nurture positive transference

Regression Enhance Minimize

Unconscious Explore Focus on conscious material

Defenses Interpret Reinforce mature defenses

Source: Reference 4 Adults with ADHD dysthymia, thoughts of harming herself, low self- esteem, and indecision about her marriage. were nearly 2x Mrs. S was not receiving mental health treatment because her fi rst experience with a psychiatrist had a poor outcome: “He hardly ever said anything; in fact, more likely to have sometimes I wondered if he was sleeping. I needed 1 advice desperately, and I was hoping to get some been divorced* help and direction for my life. Instead he answered every question with a question, and I ended up getting more confused. I felt guilty, like I wasn’t being a good patient because I couldn’t think for myself. I The consequences may be serious. felt like he thought I was stupid. He gave me some Screen for ADHD. antidepressants, but after a few months of feeling even worse I stopped going and vowed to never see a therapist again.” Find out more at www.consequencesofadhd.com 5 key components and download patient support materials, Although all have some elements coupons, and adult screening tools. of support, effective supportive psychotherapy has 5 key components (Table 2, page 32).

Adopt a conversational style. In psychoanalytic *Results from a population survey of 500 ADHD adults and 501 gender- and age-matched non-ADHD adults which investigated therapy, as experienced by Mrs. S, the therapist’s characteristics of ADHD and its impact on education, employment, opacity is intended to allow the patient to develop socialization, and personal outlook. transference. In supportive psychotherapy the ther- Reference: 1. Biederman J, Faraone SV,Spencer TJ, et al. Functional impairments in adults with self-reports of diagnosed ADHD: a controlled study of 1001 adults in the apist instead works to create a therapeutic alliance community. J Clin Psychiatry. 2006;67:524-540. based on the relationship with the patient. Using a conversational style is essential for developing this positive relationship. This style includes: Shire US Inc. • asking directive questions ... your ADHD Support Company™

• allowing infl ection in your voice ©2006 Shire US Inc.,Wayne, Pennsylvania 19087 A1410 11/06 • making gestures • discussing opinions. continued Table 2 • gaining an understanding of your 5 components of supportive role in the conflict and apologizing psychotherapy if sincere • offering solutions to improve the • Adopt a conversational style confl ict • Nurture positive transference • providing reassurance that working • Reduce anxiety through the confl ict will strengthen Supportive the therapeutic relationship. • Enhance self-esteem psychotherapy These techniques generally do not in- • Strengthen coping mechanisms clude interpreting resistance or uncon- scious confl icts. However, patients some- Some therapists are uncomfortable times benefi t from reviewing their role and with this style because they feel more perceptions in the confl ict once their anger “transparent.” With practice or super- has subsided. Waiting for the negative vision, however, therapists often learn transference to resolve on its own usually that a conversational style allows greater is not a good strategy. Clinical Point spontaneity and creativity. They can solve Help patients talk problems in a more relaxed state (closer to Reduce anxiety. In supportive psycho- about painful topics, “being themselves”). therapy, the primary goal is to lessen the patient’s suffering. Although the patient but allow them to CASE CONTINUED often must talk about stressful or painful put off discussing Learning to cope topics, you can help him or her do so in a matters too Mrs. S’s new psychiatrist starts her on an tolerable manner. Focus on making it easi- uncomfortable to antidepressant and once-weekly supportive er for the patient to talk. psychotherapy. For the initial sessions, the Reducing anxiety means not only endure psychiatrist helps Mrs. S explore options for helping the patient talk about painful her highly conflicted marriage and strategies matters but also allowing him or her to for coping with panic symptoms. avoid topics that are too uncomfortable Mrs. S develops a strong feeling of to endure. You can always “earmark” ar- attachment to the psychiatrist, sometimes eas of concern for later discussion. This projecting anger onto him by declaring modulation of anxiety is consistent with that he does not care enough. Instead of the object relations approach proposed interpreting this transference, the psychiatrist by Kohut,10 in which emotional pain is uses it as an opportunity to explore coping addressed in “small, psychologically options Mrs. S can try when she feels unloved manageable portions.” or rejected. Enhance self-esteem. Virtually all patients Nurture positive transference. A posi- in supportive psychotherapy suffer from tive relationship is essential for the low self-esteem, so it is benefi cial to help therapeutic alliance. In most instances, them feel better about themselves. Take an a patient naturally develops good feel- active role by using positive comments and ings toward the therapist over time as a acknowledgements (“plussing”) as well as result of repeated empathic interchange. compliments when appropriate. In supportive psychotherapy, you may Most patients with low self-esteem have acknowledge these good feelings but do defects in the ability to nurture or forgive not interpret them for unconscious un- themselves (“self-soothe”). Work with pa- derpinnings. tients to enhance this ability by: Address transference only if it is nega- • plussing where appropriate tive. If the patient develops hostility or an- • correcting negative self-distortions or ger toward you, use techniques to improve self-reproach the relationship, such as: • educating patients on how to both pla- • acknowledging the validity of the cate and reward themselves. Current Psychiatry 32 June 2007 patient’s angry feelings Some patients are unable to do this without external support from a significant other, family member, support group, or health care worker. In such cases, help the patient seek BROKEN out and use supports he or she needs to provide soothing.

Strengthen coping mechanisms. In supportive PROMISES psychotherapy the therapist acts as a coach, giving the patient suggestions on how to cope with diffi - cult matters. As part of treatment, you might assign the patient homework and instruct him to practice specifi c coping strategies.

CASE CONTINUED Feeling stronger Eventually Mrs. S is able to talk in a limited fashion about childhood sexual abuse. With her psychiatrist’s encouragement, she begins to write about her feelings in a journal and exercising to help her “feel strong.” Adults with ADHD The psychiatrist often acknowledges her struggle and compliments her attempts at coping in healthy were nearly 2x ways. After a year of supportive psychotherapy Mrs. S is better able to modulate her feelings and make decisions without feeling overwhelmed. more likely to have been divorced*1 An option for challenging patients Psychotic disorders. Although it may seem intui- tive that psychotic conditions are a contraindication for psychotherapy, patients with and The consequences may be serious. other psychotic disorders often benefi t immensely Screen for ADHD. from supportive psychotherapy. A supportive therapist’s guiding infl uence can help psychotic patients cope with fractured social and family life, Find out more at struggles with independence, loneliness, frequent www.consequencesofadhd.com disturbances of reality, stigmatization from society, and diffi culty with decision-making. and download patient support materials, In my experience, many patients with schizo- coupons, and adult screening tools. phrenia benefi t from refl ecting on their struggles and exploring ways to cope. Also, by repeatedly spending time with patients, a supportive thera- pist is building credibility (internalized “good” *Results from a population survey of 500 ADHD adults and 501 gender- and age-matched non-ADHD adults which investigated object) that will be needed when patients experi- characteristics of ADHD and its impact on education, employment, ence psychosis. socialization, and personal outlook. During a patient’s acute psychotic episodes, you Reference: 1. Biederman J, Faraone SV,Spencer TJ, et al. Functional impairments in adults with self-reports of diagnosed ADHD: a controlled study of 1001 adults in the can draw on the therapeutic relationship you have community. J Clin Psychiatry. 2006;67:524-540. established, strongly advising the patient to accept treatment when he or she is paranoid and rejecting help. In such situations, you might say, “Joe, you Shire US Inc. know me. You know that in the past I have helped ... your ADHD Support Company™ you get through some tough times. You are going to ©2006 Shire US Inc.,Wayne, Pennsylvania 19087 A1410 11/06 have to trust me that you need this medicine now, even if you don’t want to take it.” continued Borderline . Support- ive psychotherapy’s emphasis on reducing Related Resources anxiety and nurturing a therapeutic rela- • Werman DS. The practice of supportive psychotherapy. New York: Brunner/Mazel; 1984. tionship makes it a good treatment for pa- • Winston A, Rosenthal RN, Pinsker H. Introduction to tients with borderline personality disorder. supportive psychotherapy. Arlington, VA: American Psychiatric The focus on adaptive skills, self-esteem, Publishing, Inc; 2004. and higher order defenses—such as repres- • Pinsker H. A primer of supportive psychotherapy. Hillsdale, NJ. The Analytic Press; 1997. Supportive sion, sublimation, rationalization, intellec- Drug Brand Name psychotherapy tualization, inhibition, displacement, and Imipramine • Tofranil humor—is particularly suitable for self-in- jurious and suicidal patients.11 Disclosure In addition, dialectical behavior thera- Dr. Battaglia is a consultant to Eli Lilly and Company. py is congruent with supportive psycho- therapy.12 I have found it useful to let pa- to you”—can be a powerful intervention tients know I am experienced and strong with lasting benefi ts. enough to undergo therapy with them and Clinical Point can live with the chaos of their lives. This References 1. Stewart RL. Psychoanalysis and psychoanalytic often comforts patients with borderline psychotherapy. In: Kaplan HI, Sadock BJ, eds. Comprehensive I havehave ffoundound it useful textbook of psychiatry/IV. Baltimore, MD: Williams & Wilkins; ttoo lletet patientspatients kknownow personality disorder, as their internal state 1985:1331-65. conveys a sense of destruction not only 2. Sullivan PR. Learning theories and supportive psychotherapy. I amam experiencedexperienced for them but anyone close to them. From Am J Psychiatry 1971;128:763-6. 3. Crown S. Supportive psychotherapy: a contradiction in terms? aandnd strongstrong enoughenough a psychoanalytic perspective, conveying a Br J Psychiatry 1988;152:266-9. ttoo livelive withwith thethe sense of safety is a core healing component 4. Dewald, P. Principles of supportive psychotherapy. Am J Psychother 1994;48(4):505-18. of supportive therapy.13 cchaoshaos ofof theirtheir liveslives 5. Wallerstein RS. Psychoanalysis and psychotherapy: an historical perspective. Int J Psychoanal 1989;70:563-91. Substance abuse. A lack of treatment re- 6. Klein DF, Zitrin CM, Woerner MG, Ross DC. Treatment of phobias II. Behavior therapy and supportive psychotherapy: sponse and therapist burn-out are recur- are there any specifi c ingredients? Arch Gen Psychiatry rent problems when treating patients with 1983;(40):139-45. 7. Hellerstein DJ, Rosenthal RN, Pinsker H, et al. A randomized 14 substance abuse. I have found it useful prospective study comparing supportive and dynamic to “stretch” my treatment timeline—for therapies. J Psychother Pract Res 1998;(7):261–71. 8. Rosenthal RN, Muran JC, Pinsker H, et al. Interpersonal example, by measuring change in years in- change in brief supportive psychotherapy. J Psychother Pract stead of months—so that I don’t continu- Res 1999;(8):55–63. 9. Rockland LH. A review of supportive psychotherapy, 1986– ally feel unsuccessful. This allows me to fo- 1992. Hosp Community Psychiatry 1993;(44):1053-60. cus not on the patient’s immediate sobriety 10. Kohut H. The analysis of the self. New York: International but instead on the supportive relationship, Universities Press; 1971:229. 11. Aviram RB, Hellerstein DJ, Gerson J, Stanley B. Adapting especially on helping the patient address supportive psychotherapy for individuals with borderline personality disorder who self-injure or attempt suicide. J his or her sense of guilt and failure, which Psychiatr Pract 2004;(10):145–55. frequently underpins substance abuse. 12. Linehan MM. Cognitive-behavioral treatment of borderline Helping your patient to reframe his or personality disorder. New York: The Guilford Press; 1993. 13. Werman DS. On the mode of therapeutic action of her substance abuse as “bad choices” in- psychoanalytic supportive psychotherapy. In: Rothstein A, stead of the actions of a “bad person” is ed. How does treatment help?: On the modes of therapeutic action of psychoanalytic psychotherapy. Madison, CT: International essential. Accompanying the patient to an Universities Press; 1988:157–67. Alcoholics Anonymous meeting—“I’ll go 14. Knudsen HK, Ducharme LJ, Roman PM. Counselor emotional exhaustion and turnover intention on therapeutic with you to the fi rst one, after that it is up communities. J Subst Abuse Treat 2006;31(2):173–80. Bottom Line Although traditionally viewed as an inferior therapy, supportive psychotherapy is surprisingly eff ective for a variety of conditions. By using a conversational style and nurturing positive transference, the therapist can reduce patients’ anxiety, enhance Current Psychiatry 34 June 2007 self-esteem, and bolster coping skills.