Practice Of Supportive Psychotherapy

David S. Werman

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317772934
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

First published in 1989. This volume reflects the extensive experience of a clinician-educator in psychiatry and psychoanalysis. Dr. Werman presents a balanced, comprehensive, detailed, nondoctrinaire, and warm human treatment of the subject. He makes it clear that, while supportive psychotherapy can and should be based on psychodynamic understanding of patients, the technical principles that guide application of such understanding in supportive treatment are quite different from those guiding insight oriented therapy. Careful reflection upon the text and its many clinical examples will suggest that good supportive psychotherapy is extremely difficult and demanding of special skills.

1

Supportive Psychotherapy and Insight-Oriented Psychotherapy

The distinctions between insight-oriented psychotherapy and supportive psychotherapy, as well as their very names, have been challenged by some authors. Nevertheless, I believe that there are substantial theoretical and practical differences between the two forms of treatment, and that psychotherapists should understand these differences in order to avoid any confusion over the goals and technical procedures which might weaken either therapeutic process. The names attached here to these modalities are neither very accurate nor sharply descriptive, but they are the terms that are most popularly used, and will continue to be used since the fate of neologisms is only too well known.

Although in the following pages these two forms of treatment are compared as if they were not only different from each other but virtually dichotomous in their aims and techniques, in reality they rarely exist in pure forms. Typically, over a period of time, most patients in supportive psychotherapy gain some insight into their behavior; similarly, it is difficult to conceive of a course of insight-oriented psychotherapy in which some supportive measures are not utilized.

Additionally, while supportive psychotherapy is continually contrasted with insight-oriented psychotherapy, the therapist performing an evaluation for treatment should keep in mind that psychoanalysis may be the treatment of choice for carefully selected patients. In my view, psychoanalysis is chiefly distinguished from insight-oriented psychotherapy in that its goals are broader than symptom cure or relief, and include the further development of the patient as a person. This is important for every individual, but it is especially so for those patients whose maturity and richness of personality can have a powerful ameliorative effect on those with whom they work. Included among such individuals are not only all mental health professionals, but nonpsychiatric physicians and nurses, teachers, day-care center personnel, and clergy—to name but some of the groups to be considered. If the therapist doing an evaluation believes his patient may be an appropriate candidate for psychoanalysis, he should refer the patient to an analyst or a psychoanalytic clinic for further evaluation.

Despite the frequent use of the terms “insight-oriented psychotherapy” and “supportive psychotherapy,” daily observations in the clinical setting confirm that there are profound differences of opinion and general unclarity regarding the theoretical nature of these treatment modalities. Even more striking, is that the technical differences between them are unclear, particularly those that relate to the practice of supportive psychotherapy. Repeatedly, one sees a stereotypical adherence to rules and procedures which, at best, may be appropriate to psychoanalysis or to insight-oriented psychotherapy. Such misuse of “psychoanalytic technique” has frequently led some therapists to reject anything that appears to be related to psychoanalysis.

The central difference between supportive and insight-oriented psychotherapy derives from the therapist’s assessment of the patient. Supportive psychotherapy presumes a patient whose basic psychological “equipment” is more or less severely underdeveloped. There is little or no question of returning this individual to a former, healthy level of functioning. Optimally, this patient’s mental capacities may be strengthened; more frequently, however, he may require help from external sources for an indefinite period of time.

The analogy to a patient with diabetes mellitus is useful here: The physician who treats the diabetic patient does not attempt, by some quixotic means, to cure the insulin deficiency; rather, he tries to minimize the worst effects of the illness by supplying insulin from outside the patient’s body, he recommends a specific diet, he may prescribe insulin in order to substitute for the patient’s deficiency in this hormone, and he may recommend other useful measures. Such therapeutic steps are, by their nature, quite different from those employed by a physician in treating, for example, pneumonia, for which a specific antibiotic is administered in order that an infectious process be eliminated and the patient’s pulmonary tissues can revert to relative normalcy.

In fact, much of the physician’s work is actually supportive and substitutive, and he would never regard such life-saving and life-enhancing measures as less worthy of his efforts and skill than the strictly curative therapies. It is not always so with psychotherapists who often seem to avoid, if not disdain, supportive psychotherapy—a modality of treatment which is indicated for a vast number of individuals, can also be literally life-saving, and that optimally can render the lives of many people more pleasurable and productive.

Supportive psychotherapy refers primarily, but not exclusively, to a form of treatment whose principal concern and focus is to strengthen mental functions that are acutely or chronically inadequate to cope with the demands of the external world and of the patient’s inner psychological world. The acute deficiency, which we call a crisis, occurs when a patient whose life may previously have been in a state of reasonable equilibrium has more or less suddenly become deeply disturbed by a stressful event that may be real, symbolic, or fantasied, and that has precipitated a condition of “psychologic insufficiency.”

A model for the work of supportive psychotherapy can be illustrated by a typical example of such a crisis. Carl B., a bright, athletic, college student, who functioned well throughout his life, was overwhelmed when his girlfriend jilted him. He was afflicted with pain, sadness, and anger, and his pride was hurt. The suffering was greater than any he had ever experienced in the past, and he found himself unable to tolerate it now. He found himself unable to study or even sit in a classroom. Even his formerly careful dress and personal hygiene deteriorated. He was unable to get enough sleep, his appetite was erratic, and he considered leaving school because he was unable to concentrate on the required work. He felt that he would never find anyone else to love; he felt empty and worthless without his girlfriend.

Carl believed that his intense sadness would continue indefinitely, and he was unable to think clearly about his situation or do anything about it. He felt so worthless that not only did he believe he was incapable of benefiting from help, but he felt that no one would even want to help him. He had fleeting thoughts of wishing he were dead but no specific thoughts about suicide. Such self-destructive fantasies seemed to reflect a turning of his anger from his girlfriend against himself; indeed, he began to experience himself as unlovable, hateful, and inept. The world itself seemed to reflect his feelings of emptiness, and so he withdrew from it into feelings of despair. His distorted view of the situation and his lack of “distance” from it did not allow him to appreciate that his pain would ever abate; he could not even imagine that there might be another woman in the world who could replace his girlfriend in his affections because the entire world had grown empty without her.

In such a situation, the therapist was able to perform a number of useful tasks since his evaluation of what had happened to the patient was reasonably correct. For example, he was able to identify some difficulties Carl had with reality testing, especially as to how he saw his future and how he viewed himself as a person. He had suffered a blow to his self-esteem and temporarily regarded himself as helpless, hopeless, and therefore worthless. He was also suffering psychological pain which he was unable to throw off by suppressing it (consciously putting it out of his mind) or by sublimating it in some effective way (that is, channeling it into some useful activity).

The initial interview in itself implicitly suggested to Carl that something could be done to alleviate his pain, and that at least the therapist did not find him as loathesome as he felt himself to be; in fact, he saw that the therapist was actually able to accept him as a fellow human being who was suffering and in need of help. The therapist attempted, verbally and nonverbally, to communicate to the patient that he appreciated the extent and the nature of his pain. Seeing his feelings understood by another person was very helpful to Carl because those feelings seemed less bizarre when they were identified and accepted by someone else, especially by someone whom he could respect. He began to feel less alone.

With the early establishment of some rapport, the psychotherapist attempted to do for the patient what the patient himself might have been able to do for a friend only a few weeks earlier: He carefully explored the realities of the situation; he helped the patient find realistic solutions; and when the patient had difficulty doing so, the therapist himself made some suggestions. He tactfully challenged Carl’s unrealistic notions and illusions, and examined with him the possible consequences of one path of action or another. In this way, he helped the patient find alternatives; he made suggestions; he nurtured, guided, and helped him distinguish reality from fantasy. In short, he acted as an accepting, benevolent, level-headed parent who was “lending ego” to the patient at a time when the patient’s own ego functions were momentarily inadequate to the needs of the situation.

In many crises, the impact of the crisis situation begins to lessen in a matter of days or weeks, and the patient’s own ego resources resume adequate functioning. In fact, most psychological crises are actually surmounted without formal psychotherapy; mourning reactions are typical of these situations. Perhaps those individuals who are unable to deal with the usual life crises by themselves, or with the help of the people in their environment, are demonstrating some degree of “ego weakness.” But I believe that a significant vulnerability need not be present for an individual to be overwhelmed by a stressful event. One’s age, the particular qualities of the situation at that time, previous experience with such stress, the profound meaning of the stress to a given person—these and many other factors may be responsible for an individual’s inability to cope with a particular event. It is also true that, despite everything, there are limits to the degree of suffering each human being can endure.

I suggest that the patients who are treated in supportive psychotherapy are fundamentally similar to Carl, the student in a crisis, except that their inadequate coping is usually chronic and may be expected to continue for an extended period of time. Furthermore, their problems are not necessarily precipitated by external events, even though such events may exacerbate their preexisting difficulties. For the most part, these patients readily succumb to stresses because they have specific insufficiencies or deficits in their ego which may be qualitative or quantitative.

In contrast to crisis intervention, the following pages will focus on relatively long-term, supportive psychotherapy which has been conceptualized for the most part, as a substitutive form of treatment, one that supplies the patient with those psychological elements that he either lacks entirely or possesses insufficiently. In effect, to an important extent this description of the nature of supportive psychotherapy implies that the therapist has grasped which psychological functions in his patient are deficient and, perhaps, can be strengthened or supplied. Such reinforcement usually concerns strengthening specific aspects of ego functioning although, as will be described later, there are other ways that support can be given.

A word of caution should be added in regard to the conceptualization of the “inadequate ego functions” described here. These insufficiencies should not be regarded as meaningless or random forms of psychic “scarring” or lacunae. They generally arise (mal)adaptively at some time in the patient’s life, usually during his formative years; they may have appeared de novo later on or, more typically, they were reinforced by subsequent life events. In a subtle but powerful way, a person’s attitudes, or pieces of his behavior, have an impact on the people in his environment who usually react to the behavior in such a way as to reinforce it, for better or worse.

The paranoid patient, for example, may develop enemies because of his suspiciousness; the masochist tends to bring out sadistic impulses in others; and compassionate, generous people usually evoke these qualities in those with whom they associate.

Furthermore, these insufficiencies, deficits, and rigid maladaptive patterns of mental functioning are not only the by-products of early developmental occurrences and later reflexive situations, but they are enmeshed in current dynamic situations and encompass, often in obscure ways, many of the elements of those situations. The suspicious individual, for example, who regularly is jealous of his wife every time she speaks to another man, may be projecting his own desire to have an extramarital affair. The fact that he deals with his “ego-alien” (unacceptable to his self) desires by projection is itself a compromise that is the result of numerous intense early and later experiences. The fact that the desire itself is abhorrent also constitutes a dynamic configuration. The more the therapist regards human behavior as complex amalgams of experience, impulse, defense, and adaptation, the better is he able to be helpful to his patient.

Although the fundamental work of supportive psychotherapy consists in shoring up ego functions, that is not the only role that this treatment modality can play. At times, and for certain patients more or less frequently, supportive psychotherapy provides them with the opportunity to air their feelings; it may offer them a symbolic form of love through the contact with an empathic, helping therapist; and it can help soothe angry, frightened, guilty, despairing or humiliated feelings, when the individual is unable to do so himself. Children need comforting when they are hurt; with maturity one never loses that need for comforting, but one becomes less dependent on others for it, and more able to soothe oneself. Some people, especially patients seen in supportive psychotherapy, have never learned to comfort themselves adequately at moments of distress, and so need to receive this help from others.

It is commonly said that, to a greater or lesser extent, supportive psychotherapy concerns the giving of “reassurance.” This ill-de-fined notion has been used in various ways. Even worse, some individuals are not consistent in their use of this word. Reassurance generally means one of three different things. The first suggests that the therapist attempts to make the patient feel less pain by minimizing or denying unpleasant realities and by offering pleasing untruths. Unfortunately, this brings the therapist into collusion with the patient’s misperceptions of reality; instead of working to enhance his reality testing, it undermines it.

In specific circumstances it may indeed be useful to reinforce a patient’s denial of a frightening reality, such as impending death, when a justifiable element of hope, small as it may be, can be introduced. For example, a woman with metastatic breast cancer had had several successful remissions following treatment with radiation therapy. She asked the psychiatrist, who had been called to see her because of depressive moods, whether he thought her condition was hopeless. He replied by saying that although her illness was serious and advanced, some patients with such illness have had their lives prolonged by several years. Such an attempt to foster hope in a patient is consistent with the medical facts.

A second meaning of reassurance relates to the therapist’s em-pathic attitude which, of course, should be present in every form of treatment. The patient realizes that the therapist appreciates how he is feeling and that he even seems to be participating, to some extent, in the patient’s suffering. When a patient experiences this resonance, it tends to undercut some of his feelings of isolation and makes him feel that the therapist understands him and is attentive to his needs. It also helps the patient to cooperate in his treatment.

Finally, the reassurance which I believe is most characteristic of supportive psychotherapy occurs when the patient is unable to exercise a realistic appraisal of a given situation because his cognitive functions, chiefly his reality testing, are operating inadequately. This may be because of long-standing ego deficits or because his ability to test reality is currently overwhelmed by massive feelings. In such situations the therapist works with the patient to help him become aware of genuine possibilities, of an alternative path, of possible contingencies, and assists him to make realistic and valid choices. Such tactics, common in counseling, are important in supportive psychotherapy.

It would be amiss to say that these techniques are never used in insight-oriented psychotherapy; however, in supportive psychotherapy they are more central to the strategy than they are in insight-oriented psychotherapy. The patient in supportive treatment who is frightened, confused, and generally unable to cope with his life, or cannot do so in some specific area, can find his anxiety diminished if he works with a therapist who, with respect, permits him to express his suffering and attempts to help him deal with those problems that he is truly unable to overcome by himself. Here again, the “substitutive” nature of supportive psychotherapy is evident, in contrast to the main strategy in insight-oriented psychotherapy, which is to provide the patient with insight into himself.

In contrast to the kind of supportive psychotherapy described, insight-oriented treatment is indicated for the individual whose enduring patterns of mental functioning—his “psychic structures”—are assumed to be reasonably well developed, and whose life history demonstrates that he has generally behaved adaptively and with pleasure. To an important extent, the task of such therapy is rehabilitative in that it helps the patient return to the former level of function which he enjoyed before one or more traumatic life events rendered his psychological functioning more or less dysfunctional. In a more far-reaching sense, such therapy may also assist the patient to develop more fully as a person—a development which had slowed down or ceased at some earlier time. The fundamental technical strategy here is centered on making conscious the forces within the patient that have led to his loss of psychological equilibrium. Thus, the goal is to enhance the patient’s understanding of himself.

Insight-oriented psychotherapy seeks to alleviate painful emotional states—especially of anxiety and depression—modify ego-alien behaviors, moderate or perhaps even eliminate destructive activities, reduce neurotic symptoms, diminish behavior that leads to guilty feelings, and enhance relationships that have previously been ungratifying and even painful.

In recent years, psychotherapists have also become more sensitive to problems relating to the patient’s self-concept, issues sometimes considered under the title of self-psychology. Most commonly these patients suffer from low self-esteem, feelings of humiliation, isolation, emptiness, embarrassment, and shame; less often they are intensely centered on their own worth and are grandiose. Their complaints, however, are not usually about these personality traits.

Insight-oriented psyc...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Foreword by Morton F. Reiser
• Preface
• Table of Contents
• 1. Supportive Psychotherapy and Insight-Oriented Psychotherapy
• 2. Evaluating the Patient for Therapy
• 3. The Therapeutic Agreement
• 4. Goals of Treatment
• 5. Qualifications of the Therapist
• 6. Behavior of the Therapist
• 7. Strategy and Tactics
• 8. Transference and Countertransference
• 9. Resistance
• 10. Typical Situations and Techniques: Distortions of Reality
• 11. Typical Situations and Techniques: Independence
• 12. Typical Situations and Techniques: Impulsive Behavior and Passivity
• 13. Typical Situations and Techniques: The Silent Patient
• 14. The Place of the Dream in Supportive Psychotherapy
• 15. Changing from Supportive to Insight-Oriented Psychotherapy
• 16. Auxiliary Supportive Measures
• 17. Termination and Interruption
• Epilogue
• References
• Index