Choosing Appropriate Techniques

When today's psychiatrist does psychotherapy, it is most likely supportive psychotherapy. Because it is well-tolerated by patients and its results are at least equal to those of other psychotherapies, David Hellerstein and colleagues (1994) called supportive psychotherapy the default model and believed it should be the therapy of first choice.

Robert Knight, M.D., one of the first psychiatrists to discuss supportive psychotherapy, wrote (Knight, 1949):

Suppressive or supportive psychotherapy, also called superficial psychotherapy, utilizes such devices as inspiration, reassurance, suggestion, persuasion, counseling, reeducation, and the like and avoids investigative and exploratory measures.

He later added a list of techniques to use for supportive psychotherapy (Knight, 1952):

Instruction of the patient in areas of knowledge and adaptation where he is deficient encouragement, advice, active help in feasible management of the environment; appropriate coaxing, exhortation, kidding and praise; prescription of daily activities, including mental hygiene reading; provisions of support through a nurse or companion; long range support through less frequent continuing supportive interviews as the patient improves.

He also included hospitalization as an option.

Knight had a psychoanalytic perspective. For healthier patients, expressive, exploratory or psychoanalytic therapy was preferred. For the more psychologically impaired patient, supportive therapy was the treatment of choice. The purpose of supportive therapy was to "reconstruct the defense mechanisms and adaptive methods [of the patient] before his decompensation" (Knight, 1952).

The model for supportive psychotherapy Knight proposed is similar to the one we use today. Knight's devices, now called techniques, however, have steadily increased in number as each subsequent author has added new ones.

One of Misch's (2000) suggested techniques, for instance, is to capitalize on the therapist as a role model: Let the patient see how the therapist handles anger, confusion, embarrassment, disappointment and failure. He noted:

The supportive therapist is a good selfobject, providing needed mirroring, idealizing, and twinship experiences that allow the patient to internalize important psychological functions that are currently deficient.

Additional techniques include self-esteem maintenance through the use of empathy (Luborsky, 1984), help in dealing with a severe conscience (Luborsky, 1984), modulating affect (Misch, 2000), developing a liking for the patient (Luborsky, 1984), facilitating the helping or working alliance (Luborsky, 1984), achieving emancipation from parents (Andreasen and Black, 1991), gratification of dependency needs (Kaplan and Sadock, 1985), reframing (Rockland, 1989), and many more.

It is important to distinguish between supportive techniques and supportive psychotherapy. The terms are often used interchangeably, leading to confusion. Almost all psychotherapies use some supportive techniques. For instance, the therapist's avoidance of value judgments, present in virtually all therapies, is very supportive for most patients. Only when a therapy is primarily composed of supportive techniques does it become supportive psychotherapy (Luborsky, 1984).

Considering the large and often disparate number of techniques described, therapists need a method or underlying theoretical formulation to guide them in their choice of appropriate supportive techniques, whether it is supportive or any other therapy.

Knight's original guideline, using techniques that will strengthen the patient's defenses, has remained intact (Knight, 1949). Recent additional guidelines tend to be similar to the one recommended by Misch (2000): Do for the patient what a good, mature and loving parent would do. These guidelines are useful; however, they are often insufficient.

The supportive psychotherapist is the gratifying therapist, as opposed to the psychoanalyst who, for the purpose of achieving an eventual cure, withholds from the patient and eschews fulfilling the patient's dependency needs. The supportive therapist is active, talks more to the patient, does things for the patient and engages in direct actions to help the patient. To accomplish this, a variety of techniques are used. I have found it helpful to conceptualize the techniques on a continuum, based on whether the therapist's activity is directed to environmental change or to improving the patient's adaptive capacity.

In this "Outer-Inner Continuum," there are five points (Figure). The range is from outer, which refers to the external world of the patient, to inner, which refers to the conscious thinking and feeling of the patient. The positive changes the patient is able to make based upon more adaptive ways of handling thoughts and feelings will have a greater therapeutic effect than will simply following the therapist's instructions. For some patients, however, there can be little doubt that frequent monitoring by a therapist is very beneficial.

At the outer end of the continuum the therapist is acting on behalf of the patient. This includes hospitalizing the patient, prescribing medication and advising the family to make environmental changes. The patient is primarily passive. All the activity is done for the patient, by the therapist.

At the next stage along the continuum, the therapist is not acting on behalf of the patient. The therapist is advising and guiding the patient to take actions the therapist believes will be beneficial. The therapist's activity is limited to directing the patient, but it is the patient who is performing the actions. The patient makes a behavioral change under the direction of the therapist.

At the middle of the continuum, the therapist no longer acts for the patient or offers advice. The therapist's sole activity is to reinforce or praise what the patient has already done on their own initiative.

At the inner end of the continuum, the therapist does not focus on behavior but helps the patient develop more mature ways of thinking about important areas of their life, such as improving relationships or setting realistic goals.

Finally, at the innermost end of the continuum the therapist helps the patient deal with feelings such as unrealistic severe guilt, anger or anxiety.

To the extent that it does not create anxiety for the patient, the therapist should use techniques that are toward the inner end of the continuum. The assumption is that inner-continuum techniques will help patients improve their adaptive capacities, resulting in more autonomy and greater therapeutic success.

The following case illustrates the advantages of shifting from an outer-continuum technique to an inner-continuum technique (Blanco et al., 2001). This case used interpersonal psychotherapy, not supportive therapy, but many standard supportive techniques are used in the case description.

Ms. A, a 38-year-old married mother of three daughters, became moderately depressed after learning her husband had a second wife and two children in a foreign country. At the start of treatment, "the therapist repeatedly raised the possibility of reconsidering the marital arrangement, but Ms. A made it very clear that leaving her husband was not an alternative she was willing to entertain." This advice or suggestion, a standard supportive technique, belongs in Category 2. This intervention was unsuccessful.

The therapist then shifted the approach. Using supportive techniques from Category 4, he reviewed with the patient many of her assumptions and customary ways of thinking about important aspects of her life. Some examples of this were: 1) He "helped the patient explore ways of initiating change in the relationship"; 2) The patient "worried that bringing up her feelings would lead to fights between [her and her husband], resulting in her eventually receiving less attention from him. The therapist examined this assumption and helped her explore ways of saying [to her husband] how she felt"; and 3) difficult situations were discussed and "how she felt in those situations and what could be alternative, more adaptive behaviors in response to such situations."

The supportive psychotherapy techniques were used within the context of an interpersonal psychotherapy. The patient improved when the therapist moved from an outer, Category 2, supportive technique to an inner, Category 4 technique. Her Hamilton Rating Scale for Depression (HAM-D) score decreased from 25 to 6.

This case tends to support the theory that the use of supportive techniques, which are intended to increase the patient's adaptive capabilities, can be more therapeutically beneficial than are techniques designed to guide the patient's behavior based on decisions made by the therapist.

References:

References

1.

Andreasen NC, Black DW (1991), Introductory Textbook of Psychiatry. Washington, D.C.: American Psychiatric Press.

2.

Blanco C, Lipsitz J, Caligor E (2001), Clinical case conference: treatment of chronic depression with a 12-week program of interpersonal psychotherapy. Am J Psychiatry 158(3):371-375.

3.

Hellerstein DJ, Rosenthal RN, Klee S (1994), Supportive therapy as the treatment model of choice. J Psychother Pract Res 3(4):300-306.

4.

Kaplan HI, Sadock BJ (1985), Modern Synopsis of Comprehensive Textbook of Psychiatry, 4th ed. Baltimore: Williams & Wilkins.

5.

Knight RP (1949), A critique of the present status of the psychotherapies. Bull N Y Acad Med 25:100-114.

6.

Knight RP (1952), An evaluation of psychotherapeutic techniques. Bull Menninger Clin 16:113-124.

7.

Luborsky L (1984), Principles of Psychoanalytic Psychotherapy: A Manual for Supportive-Expressive Treatment. New York: Basic Books.

8.

Misch DA (2000), Basic strategies of dynamic supportive therapy. J Psychother Pract Res 9(4):173-189.

9.

Rockland LH (1989), Supportive Psychotherapy: A Psychodynamic Approach. New York: Basic Books.