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SUPPORTIVE PSYCHOTHERPY: PRINCIPLES AND PRACTICE
OUTLINE OF PRESENTATIONDEFINITIONHISTORY OF SPT GOALSINDICATIONSSPECIFIC DISORDERSPRINCIPLESTHEORIESTECHNIQUESREVIEW OF STUDIESCONCLUSION
DEWALD (1994) aimed at symptom relief and behavior change without emphasis on modifying personality or resolving unconscious conflictsWERMAN (1984) - a substitute treatment, which supplies the patient with those psychological elements, which are lacking or possessed insufficientlyWALLACE (1983) - a therapy to augment the patients adaptive capacity and to re-affiliate the patient with others.Other names: Palliative psychotherapy, social therapy, situational therapy and milieu therapy.
History of SPTAccording to PsycINFO the first indexed work bearing the term supportive therapy appeared in a paper by Billings in 1939.Robert Knight (1949) was the first one to use the concept of supportive therapy in a psychoanalytic frame of referencethe pure gold of psychoanalysis should be mixed up with the copper of direct suggestion (Freud, 1919)
Eissler (1953) argued for the inclusion of temporary supportive parameters into the psychoanalytic method. Some analysts felt this change in methodology was a threat to analysis (Stone, 1954)Others meant this broadening was a way for psychoanalysis to develop even further in techniques towards a more supportive stance and thus include supportive technology (Alexander, 1954)
Wallerstein & Robbins (1956) went a step further and constructed a tripartite scheme with supportive psychotherapy at one end, psychoanalytically oriented psychotherapy in the middle and psychoanalysis proper at the other end; the last mentioned representing the most full-blown form of psychotherapy. On the History of Supportive Therapy Nordic Psychology, 2007, 59 (2) 181-188
Empirical verification later showed that supportive psychotherapy was in fact as effective as psychoanalysis, surprisingly sometimes even better (Wallerstein, 1986).Ira Miller (1969) made a point of showing that the psychoanalytic interpretation can be supportive, too. Miller also asked if it was possible to conceptualize a therapy that was not supportive: arent all therapies supportive?
The first book dealing exclusively with supportive psychotherapy, The practice of supportive psychotherapy, was published by the psychiatrist David Werman in 1984, followed by books by Rockland (1989) and Novalis, Rojcewicz andIt is important to mention the development during this period of time toward object-relational theories in psychoanalysis (Kernberg, 1976) and Heinz Kohuts (1977) self-psychology, where at least the latter put great emphasis on the support of the self
The researchers at Beth Israel Medical Centre in New York made great efforts to transform supportive psychotherapy into a frontline therapy, with elements from cognitive behavioural therapy goal setting, use of diary and agenda integrated with the supportive therapy from the psychoanalytic tradition (Pinsker, Rosenthal & McCullough, 1991). Hellerstein,
Pinsker & Rosenthal (1994) claimed that supportive therapy should be a kind of Basic psychotherapy; the first choice when people ask for psychotherapyThe work of integration went even further with the development of truly integrative variants of psychotherapy, where supportive therapy clearly has assimilated concepts from both systemic and cognitive-behavioural methods (Misch, 2000). On the History of Supportive Therapy Nordic Psychology, 2007, 59 (2) 181-188
GOALSPrimary Goal: Symptom relief or symptom removal.Objects:To bring the patient to emotional equilibrium Amelioration of the symptoms, so that he can function at a level approximating his norm.Strengthen existing defenses To elaborate better mechanisms of control. To remove or reduce detrimental external factors that act as source of stress.
There is no intent to change the personality structures, less ambitious, less anxious, less intensive.Supportive measures thus may be utilized as the principal treatment or as adjuncts to re-educative or re-constructive psychotherapy. They are employed as:A short term exigency or expedient for basically sound personality structures momentarily submerged by transient pressures that the individual cannot handle.
A primary long term means of keeping borderline and characterlogically dependent patients in homeostasis.A way of ego building to bring a person to a pint where he can devote himself to more re-integrative psychotherapeutic tasks.A temporary expedient during insight therapy when anxiety becomes too strong for existing coping capacities. (Ref: Book - Wolberg, The technique of psychotherapy, Part one)
INDICATIONSSupportive psychotherapy was described for years as the treatment for individuals not suitable for expressive therapiespersons who are difficult to treat or for whom expressive techniques are expected to fail. (Winston et al. 1986, Rosenthal et al. 1999).
Supportive psychotherapy was said to be indicate d for people who have1. A predominance of primitive defenses (e.g.,projection and denial); 2. An absence of capacity for mutuality and reciprocity, exemplifying an impairment in object relationsAn inability to introspectAn inability to recognize the object as separate from the self, because of malignant narcissism or autism
5. Inadequate affect regulation, especially in the form of aggression; 6. Somatoform problems; and 7. Overwhelming anxiety related to issues of separation or individuation (Buckley 1986; Werman 1984).
Crisis, which includes acute illnesses that emerge with the overwhelming of the patients defenses in the context of intense physical or psychological stress; and Chronic illness with concomitant impairment of adaptive skills and psychological functions
SPT in specific disordersAdjustment disorders,in relatively well-compensated people: Supportive psychotherapy can at least help the patient to manage uncomfortable feeling states and to shore up or develop coping strategies while the patient and therapist wait for the episode to end.
Acute bereavement: the use of healthy defensive operations, concrete assistance for routine activities the patient is not able to performappropriate reaching out as a measure against the tendency to remain socially withdrawn (Novalis et al. 1993).
Chronic Illness :Compared with individuals in crisis, individuals who must cope with chronic mental illness are more traditionally associated with supportive psychotherapy and are more likely to entail longer-term therapy (Drake and Sederer 1986; Kates and Rockland 1994; Werman 1984).
Applicability to Special PopulationsSchizophrenia: Gunderson and colleagues (1984) demonstrated that patients with schizophrenia have better treatment retention and better outcome when given weekly supportive treatment as compared to more intensive expressive treatment
Medical illnessReducing pain intensity and interference with normal work, sleep, and enjoyment of life in patients with HIV-related neuropathic pain (Evans et al.2003);Reducing the frequency and impact of stressful events in patients with primary (Hunter et al. 1996) or metastatic (Classen et al. 2001) breast cancerTreating HIV-positive patients with depression (Markowitz et al. 1995); Treating patients with pancreatic cancer (Alter 1996)
Treating cancer patients with depression (Massie and Holland 1990) Chronic pain (Thomas and Weiss 2000); and Treating hospitalized patients with somatization disorder (Quality Assurance Project 1985).
Personality Disorders: Rosenthal and colleagues (1999) demonstrated lasting change in interpersonal functioning among patients with Cluster C personality disorders who were treated with 40 sessions of manual-based supportive psychotherapy.
In addition in patients with major depression and personality disorders (especially Cluster C personality disorders), short-term (16sessions) supportive psychotherapy in combination with antidepressant treatment reduces personality pathology compared with antidepressant treatment alone (Kool et al. 2003).
Substance use disorders:Kaufman and Reoux (1988) suggested that in the case of patients with substance dependence, expressive therapies (when appropriate) should not commence until the patient has implemented a concrete method of maintaining sobriety, because expressive therapies provoke anxiety that may trigger relapse.
Substance Use Disorders:Supportive psychotherapy with substance use disorder patients focuses on helping the patient to develop effective coping strategies to control or reduce substance use and stay engaged in treatment.
Other important aspects are developing and maintaining a strong therapeutic alliance and helping the patient to both reduce and learn to manage anxiety and dysphoria in order to minimize the risk of relapse.
Contraindications: Supportive psychotherapy is contraindicated when psychotherapy itself is contraindicated. Novalis et al (1993) suggested that supportive psychotherapy is unlikely to be effective in delirium states, other organic mental disorders, drug intoxication, and later stages of dementia but these are conditions in which any psychotherapy could be expected to fail.
PrinciplesPinsker (1997) and others (Misch 2000; Novalis et al. 1993) described general principles of supportive psychotherapy:Positive feelings toward and positive transferences to the therapist are generally not focused on in supportive psychotherapy, in order to sustain the therapeutic alliance
The therapist is alert to distancing, negative resp