546674

research-article2014
APY0010.1177/1039856214546674Australasian PsychiatryHarari

Australasian
Psychotherapy Psychiatry
Australasian Psychiatry

Supportive psychotherapy 2014, Vol 22(5) 440­–442

© The Royal Australian and
New Zealand College of Psychiatrists 2014
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DOI: 10.1177/1039856214546674
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Edwin Harari  Consultant Psychiatrist, St Vincent’s Hospital Area Mental Health Service,
Fitzroy, VIC, Australia

Abstract
Aim: The aim of this article is to describe the principles of supportive psychotherapy.
Conclusion: The author illustrates the principles of supportive psychotherapy with a case vignette.
Supportive psychotherapy is an important clinical skill for all psychiatrists.

Keywords:  supportive psychotherapy

T
he principles of supportive psychotherapy interpretation offered by a therapist in psychodynamic
form part of the foundations of the doctor-patient therapy closely resemble the empathic summary of a
relationship in medical practice, and of all psycho- patient’s distress provided by a therapist in supportive
therapies. As a specific form of psychotherapy, it is use- psychotherapy.2
ful for two groups of patients:1
1. A previously well-functioning person psychologi-
Techniques
cally destabilised by one or more life events, typically
involving loss, e.g. betrayal in a relationship, divorce, Contrary to a popular misconception, supportive psy-
illness in oneself or other, bereavement. Therapy aims chotherapy requires more than the doctor listening sym-
at restitution of the psychological status quo ante, if pathetically to the patient for a few minutes or expressing
that’s all the patient wants. concern for the patient’s plight.
Emotionally attuned listening: the doctor listens to the
2. Patients with a chronic or recurrent disability, e.g.
patient’s story, the feelings the patient expresses and
chronic physical illness often with associated pain
non-verbally communicates, and the doctor’s own ‘gut’
and/or handicap (e.g. rheumatoid arthritis, multi-
responses. The unsaid is also important; thus, a medi-
ple sclerosis), or a chronic form of mental illness,
cally ill patient who complains endlessly about treat-
including personality disorder. Supportive psycho-
ment may be avoiding the frightening question ‘am I
therapy aims to minimise deterioration and max-
going to die?’
imise competence within the limitations imposed
by the illness, the patient’s personality and circum- An empathic paraphrase of what the patient said and
stances, and the treating system’s resources. It may the doctor’s understanding of the patient. Thus, to
be combined with psychoeducation or psychotropic a paranoid patient who prevaricates and asks many
medication. questions about a proposed medication, the psychiatrist
may say:
Supportive psychotherapy has a specific meaning
‘From what you tell me, John, people have always let
derived from psychoanalysis, which describes the thera-
you down, so you try to be strong and not depend on
pist’s support for the patient’s adaptive or more mature
anybody. I think you’re worried these tablets might
personality defences. Thus, a degree of denial may
remain unchallenged in the psychotherapy of a seri-
ously ill medical patient if it enables him to persevere
with a potentially life-saving treatment. Similarly, a
patient with a borderline personality disorder who is Corresponding author:
about to sit an exam may be allowed to rationalise that Dr Edwin Harari, Consultant Psychiatrist, St Vincent’s Hospital
exam stress caused him to forget his girlfriend’s birthday, Area Mental Health Service, 46 Nicholson St, Fitzroy, VIC,
rather than exploring the possibility that such forgetting 3065, Australia.
may be an expression of his resentment. Some forms of Email: edwinharari@hotkey.net.au

440
Harari

make you weak. Maybe that’s why you don’t trust me FB (silent, sullen, eyes downcast, slumped
or the tablets?’ in his chair; he remains silent).
Consultant (gently): I wonder what might have upset
Clarification and explanation of the nature of the patient’s you? (Silence.)
difficulties and how they may be investigated and FB (mumbles): It’s the third time, this is the
helped. third time.
Reassurance and encouragement: This is not false opti- Consultant: It’s the third time you’ve had a
mism, but is reality based. So, with the aforementioned kidney transplant? (FB nods, but
patient: ‘John, I believe this medication will help calm doesn’t raise his head). And it’s too
your stress. Could you agree to try it? I’ll be here, because much for you? It’s more than you
I want to know if it’s helping and not making you weak. expected?
If you try it but don’t like it, you can tell me, and I will
FB (nods): I’ve been in three times, January
try to change it.’
2008, July 2011, and now (the
clinical impression is clearly not one
of delirium or steroid- induced agi-
Advice
tation).
The psychiatrist’s advice is based on professional knowl- Consultant: You’re right. Nowadays, kidney
edge, e.g. medication effects, the usefulness of a support transplants aren’t meant to be so
group or of taking time off work. In other matters, refer- hard. You were sick for so long,
ral to a service that deals with specific concerns is appro- then three transplants! I can
priate. imagine how each time you got
Generally, the psychiatrist avoids giving advice, but your hopes up, had the opera-
instead explores the patient’s difficulty in making a deci- tion, and then you got sick again.
sion. Typically, this reflects interpersonal problems or That could make you very wor-
the anticipated consequences of change. Reminding the ried and scared.
patient of how he went about achieving a recent success FB (nods): My wife worries a lot too; she’s all
may also challenge helplessness. by herself in W…
Consultant: So you’re in hospital, far from
Spouse and family home, worrying why the trans-
plants aren’t working; you
They are often a resource for the patient. They also have also worry about your wife,
their own distress which may also affect the patient, and you’ve just started your future
for which they may require supportive psychotherapy in together, and I guess you don’t
a couple, family or group mode. This may be combined want to show her that you’re
with specific further interventions, e.g. family psychoe- worried (he nods). That’s a lot
ducation, hospitalising the patient, or psychotherapy for for you to carry all by yourself!
a family member. (Silence.)
FB: I also wanted to go to the funeral.
Consultant: Which funeral?
Case example
FB (begins to cry): Bill, a friend.
Fred B is a 38-year-old, recently married farmer from rural
Victoria, with a history of chronic kidney disease, currently Consultant (after a Bill was important to you?
hospitalised for his third kidney transplant operation. The silence):
previous two grafts failed. The renal unit requested an urgent FB (sobbing, nods): He was like my second dad. He
psychiatric consultation following a ‘code grey’ alert when gave me my first job, and helped
Fred became agitated, verbally aggressive, threatened to pull me out with money when the
out his intravenous (i/v) and dialysis lines and to leave farm wasn’t going right.
hospital.
Consultant (gently): Could you tell us what happened
After introducing myself and other members of the psychiatry to Bill?
consultation-liaison team:
FB: He was sick for a long time, lung
Consultant: Your kidney doctors asked us to
cancer (cries).
see you because they’re worried
that you got upset. Could you tell Consultant (softly): That’s a cruel disease (silence).
us what’s happening for you? Did you know he was dying?

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FB (nods tearfully): I saw him in January, but I didn’t fix things, when there’s a prob-
get to see him again; I rang a cou- lem; I guess that’s what a farmer
ple of times but he couldn’t talk; has to do to survive (he nods).
then I got crook, and I couldn’t And I sense that you’re feeling a
go to the funeral last week. bit guilty and ashamed for get-
Consultant:
So you didn’t get to say goodbye ting angry and losing control, but
to Bill? (nods). And his family – you just couldn’t see a solution
do they know you’re crook? at the time (he nods; we are both
FB (nods, talks of his close relationship silent, but unlike the initial silence
with Bill’s family). it is not uncomfortable. Fred seems
calm and thoughtful, occasionally
Consultant: So you’re very sad about Bill, a glancing at me as if to check that
special friend, but you didn’t get I am accepting him as he is in this
to say goodbye, and you couldn’t moment; I feel that we are in a state
help (Bill’s wife) in her sadness, of silent, mutual emotional syn-
plus you worry for your wife and chrony).
your future hopes together, espe-
cially because the transplants are Consultant: Fred, I appreciate you telling us
going wrong. That’s a lot to handle about your worries and the anger;
by yourself, Fred, but you couldn’t I hope you feel I’ve understood?
actually do anything because you (He nods.) We can talk again on
were stuck in hospital!! Friday. If it’s OK with you, we’ll
explain your worries to the
FB (sitting forward in the chair, mak- nurses, so you can talk to them
ing eye contact with me for the first if those worries build up again
time, his voice trembles but is clear): inside you. People find that often
I felt I was going to explode. I happens when they’re stuck in
just wanted to leave, it’s not the hospital, especially at night. My
staff’s fault, but I was just so … so colleague, Dr A (the psychiatry
…(hesitates.) registrar), will drop in to see you
Consultant: So? … tomorrow. And we should meet
your wife when she’s here to see
FB (pause): Angry. I know it was wrong.
how she’s coping. Also, I think
Consultant: Well, you care about people, Fred, you or your wife may have ques-
and you try to be fair, so maybe tions that your kidney doctors
getting angry isn’t easy for you could help answer, so we can talk
(pause; Fred is looking intently at about that too.
me). And with whom could you
FB: Thank you, doctor (he shakes my
be angry? The staff just try to
hand warmly).
help, you knew that, but you felt
so scared and worried; but you
couldn’t do anything about it, This case has been de-identified.
you were helpless, so you blew
up with anger. Disclosure
The author reports no conflict of interest. The author alone is responsible for the content and
FB: That’s exactly right. (He sits back writing of the paper.
in the chair, appears relieved and
calm.) I’m sorry, doc. (He looks References
directly at me as if he is waiting to
1. Bloch S. Supportive psychotherapy. In: Bloch S (ed.) An introduction to the psychothera-
see if I will accept his apology.) pies. 4th ed. Oxford: Oxford University Press, 2006, pp.215–235.
Consultant: Fred, I think you’re the kind of 2. Hartland S. Supportive psychotherapy. In: Holmes J (ed.) Textbook of psychotherapy in
man who wants to do things, to psychiatric practice. Edinburgh: Churchill Livingstone, 1991, 213–235.

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