Supportive Psychotherapy
Since the beginning, compared to other psychotherapies it is considered as an
‘inferior’ therapy and is referred to as “Cinderella of Psychotherapies”, which can be
used in multitude of clinical scenarios and settings.
It is suggested that practice of S.P. is based on the principles of self-psychology, some
aspects of object relation theory, ego psychology and the attachment theory.
Definition
Provision Support is the chief component of treatment and therapist-patient
relationship important.
Word support - supportare:
sup = sub + portare - to carry (webster's new world twentieth century dictionary (2nd
edition).
So, therapist carries the patient
- he helps to prof him up, to sustain him,
- to keep him from falling or sinking.
Pinsker (1997) defined "SP as a body of techniques, or tactics, that function with
various theoretical orientations as a ‘shell program’ function with a computer's
operating system. A therapist's operating system is the theoretical orientation that
gives direction to his or her interventions. "
Recently, Winston et al (2004), defined SP as a "dyadic treatment that uses direct
measures to ameliorate symptoms and maintain, restore, or improve self-esteem, ego
function, and adaptive skills. To accomplish these objectives, treatment may involve
examination of relationships, real or transferential, and examination of both past and
current patterns of emotional response or behavior. "
Aims of S.P.
- To promote the patients best possible psychosocial functioning by restoring and
reinforcing his abilities to manage his life.
- To poster his self-esteem & self-confidence.
- To make him aware of reality - his own limitations.
- To forestall a relapse of his condition
- To give only a limited degree of support to patient. so that he adjusts well in society
+ to prevent undue dependency.
- To transfer the source of support - family of friend (depending upon the availability
and adequate role of support gives).
Indications for SP
● Stressful circumstances: such as bereavement, divorce, loss of job, menopause,
physical illness and academic difficulties.
● Severely disturbed/ poor ego strength: those who are severely handicapped,
either emotionally and/or interpersonally because of chronic schizophrenia, a
chronic affective disorder or some extreme form of personally disorder. The
therapist sees no prospect of fundamental improvement in these clients, but a
continuing need exists to help them achieve the best adaptation possible.
● Ego building measure: it can be used to encourage dedication to more
reintegrative psychotherapeutic tasks.
● Temporary Expedient: 'SP' is also indicated as temporary expedient during
insight-oriented therapy when anxiety becomes too strong for the coping
capacities.
● Lack of curiosity about self: 'SP' is indicated for those who are not curious
about themselves and their psychological functioning.
● Need for symptomatic change without any self-initiative: clients whose
interest is predominantly in symptomatic change and whose capacity for
self-initiating behavior is limited.
● Feasibility issues for other form of therapies: reality resources preclude the
necessary frequency or expenses of intensive psychotherapy.
The therapist and patient relationship
-pt. should make use of the trusting, intimate relationship which is the basis of almost
all therapies.
- only a modest level of closeness.
- like- parent-child relationship-therapist offers-security + caring on which the patient
depends.
General principles of SP
• Establish a good therapeutic alliance
• Draw a therapeutic contract, which should include do's and don'ts for the client
and the therapist, exact payment and mode of payment, duration and frequency
of sessions, mode of contact during the crisis, etc.
• Number of sessions: determined by client’s need and motivation
• Set the ground rules, such as no physical or verbal aggression in the therapy
session, not to come in intoxicated state,
• Explain the client about the role of the client and the therapist in the therapy
• Set goals for the therapy
● Don't try to structure the session
• Be non-judgmental
● Try to emotionally connect with the client
• Identify client's strengths
• Avoid argument, denigrating, and criticism
● Avoid questions starting with 'why' and 'why didn't you'- replace it by "can you
explain reason of doing things in this way"
• Explain the client that the therapy is not the alternative for pharmacotherapy,
especially in clients with severe mental disorders, or those in whom,
pharmacotherapy is definitely indicated
● Follow a conversational style
● Maintain a supportive stance
● Be active in the session, but not too active
• May use expressive measures, without diluting the supportive stance
• Do not ask too many questions, but if a question is asked, then do not abandon
the topic, without getting the answer
● No homework assignments
● No formal termination
Techniques
1- Praise
● When should be based on patient’s value and goal. (Not the therapist)
● reinforcement of accomplishments or of more adaptive behaviors (provided
that the patient is likely to agree for praise).
Example
Pt: - I took my medicine every day last week.
Therapist - Good. You said, you were going to do this & not skip a single dose and you
did it. (Reinforcing self-control and discipline).
2- Reassurance.
If the patient demands reassurance and this reassurance is outside the expertise of
the therapist the basis for the reassurance should be made explicit.
● Normalizing: - for most people, is a palatable form of reassurance.
- Pt - Wherever I go anywhere, I have this fear that I'm going to lose control.
- The People with social phobia always fear losing control; however actually losing
control is not part of the condition. (Reassurance based on principle)
3- Encouragement
- It is powerful people want to believe that their efforts will lead to something
- Sue. Invokes the world of childhood where adults do things for the child’s
benefit.
- Exhortation is a more insistent form of encouragement'
Exp.
patient - I'm eating ok, I sleep well, but I can't get going. My house is a mess. And they
want me to take one of those welfare' jobs.
Therapist -Once the depression is better, is to force yourself to begin doing things
even though you don’t feel like it. lining in a mess reminds you every day that you
can't function is bad for your self- esteem, too, so foreseeing yourself to clean up
helps.
- The discussion for the encouragement this for has dealt only one of the two
meaning of the word encouragement
that is, “to stimulate,” to spin, to give hope, “hope.”
4- Reframing and Rationalizing
● Reframing Involves looking at something in a different light or form a different
perspective
Patient- I was so stupid. I got a parking tidal, and I could have been back before the
meter ram out. I wasn't paying attention.
Therapist -- Yeah. That's tough. If you figure it’s bound to happen occasionally,
you can think of some of parking tickets a year as a routine cast of having a car.
• (Rationalization. The patient also benefits from discovering that the therapist, who
represents the adult world, does not think she is stupid.).
- Challenge in using rationalizing and reframing is to avoid sounding factors and to
avoid what may appear to argument or contradiction.
5- Advice and Teaching
- Advice is meaningful when the patient sees it as prominent to his / her needs.
- offering advice to a dependent person can be gratifying but may deprive the patient
of the opportunity to glow.
-If the patient senses that the therapist is proposing advice that is not clearly a
response to the patient’s need (e.g. that reflects the therapist’s prejudices or
convictions), the alliance will be damaged.
Example
-Therapist- You can get regular exercise.
- Patient: What for?
- Therapist: Everyone should. Obesity is a major problem in this country. (General
statement no relevance for patient).
- Therapist: A number of exercise studies have shown that exercise reduces the
indices symptoms of depression. It can reduce the amount of medication needed. If
you do it & it don't help, you haven't lost much.
- Patient: My husband humiliated me in public again. Yesterday. I screamed at
him. When we got home & he said I was too sensitive. I can't take it anymore.
- Therapist: - Have you considered couples therapy? (possibly good advice
although at times suggesting more therapy or a new therapist is used as a tactic
for ending discussion)
6- Anticipatory Guidance
● Rehearsal, or A.G., is a technique as useful in supportive psychotherapy as in
C.B.T.
● The objective is to consider in advance What obstacles there might be to a
proposed course of action & then to prepare strategies for dealing with them.
7- Reducing & preventing anxiety.
● Not only to deal with overt anxiety or symptoms, but to prevent emergence of
anxiety.
● avoid interrogative style - asking continuous questions.
● To minimize anxiety, the therapist-shares his or her agenda with patient, making
clear the reason for questions or topics.
Example: -
Therapist 1- I want to ask questions that will test your memory & concentration.
Therapist 2- Your relationship with your daughter. you said, was a major worry, is
there anything new there?
Therapist 3 - Did you grieve When your father died?
some people have little response, & it’s all right, but some don't have any response at
the time but have it bottled up.
Note- Therapist 3- Extra explanation (reduces the impact)
8- Naming the Problem.
● The patient's sense of control may be enhanced, thus anxiety minimized by
naming problem.
● The need of control is one reason why human beings find pleasure in counting
and classifying.
● Naming the problem is also meeting the familiar medical responsibility of
explaining the diagnosis, prognosis, proposed treatment.
Example: - O.C.D.
9- Expanding the patients Awareness
● clarification - summarizing, paraphrasing sing of organizing what the pt. has
said.
● Clarification - simply demonstrates that the therapist is attentive & is processing
what he or she hears.
Patient - I can't get the things done. I have to sell the house, but first I have to get
some things fixed & I don't do it.
Ex-wife- for unpaid child support
- I am bipolar, my ear broke down again, too.
Therapist- It sounds like you' are saying that you're overwhelmed.
10- Confrontation
- means bringing to the patient's attention a pattern of behavior, videos, of
feelings he of the has not recognized or has avoided.
Patient - I'm living alone in that big house. If I sell it, I can get a smaller place and have
money left over, but I just don't. do anything. I’ am so depressed.
Therapist - It sounds like you one avoiding doing the one thing that would provide you
enough money to pay your bills and give your ex-wife What she wants. (Depression is
a universally used word the knows that)
11- Interpretation
- the meaning of the patient’s thoughts as the Intent of his behavior.
- others limit the term to a linking of current feelings, thoughts or behaviors with
events of the past of the relationship with the therapist.
- Linking all 3 elements is important for achieving the objectives of expressive
psychotherapy.
- In S.P. patient- therapist- linkages are generally, made only when necessary to
avoid disruption of treatment.
12- Therapist's Basic Stance: conversational, responsive, free flow of material is
not essential, non-intrusive.
13- Understanding: empathy, employ facilitating utterances that do not appear
mechanical or insincere.
14- Question: avoid questions starting with "why"
15- Observation about underlying meaning: avoid a stance that might contribute
to distortions
16- Transference: positive transference is not interpreted but identified aspects
of the client's relationship with the therapist may become a model for
understanding interaction with other people.
17- Ventilation: Ventilation is encouraged, but therapist must learn how to
interrupt or break the flow, how to subtly encourage the client to stick to the
topic, which reduces anxiety inducing disorganization
Techniques of SP
• Guidance is a form of psychotherapy that provides active help in areas such as
education, employment, health, and social relationships. It aims to address
specific disturbing problems and provide instructions for detecting, examining,
and avoiding stressful situations. Courses of action are outlined, and
recommendations may be made towards adaptive goals like enhancing one's
career or furthering their education.
• Tension control is another technique used to regulate emotional disturbances,
which can continue to torment the individual even after neurotic defense
mechanisms have been established. Techniques such as relaxation exercises,
self-hypnosis, meditation, and biofeedback can be helpful, but their value is
greater when combined with other forms of psychotherapy.
• Environmental manipulation involves defining and eliminating pro-vacating
environmental irritants or addressing deficits in the client's living situation. The
efficacy of environmental manipulation depends on the dedication and skill of
the involved personnel, the environment's alignment with the client's needs,
and the client's reaction to what is being done for them. Examples of
environmental manipulation include home treatment, hospitalization, day
hospitals, and rehabilitation houses.
• Externalization of interest is another technique used to encourage the client to
resume activities that were once meaningful to them or develop new diversions
for leisure time. Activities such as sports, games, craft, photography, and fine
arts can help reduce social isolation and expose the client to group dynamics.
Occupational therapy is a popular method for entering the inner world of the
withdrawn and regressed client. Creative therapies such as art therapy, music
therapy, and drama therapy can be used as adjuncts to traditional
psychotherapeutic procedures, serving as supportive and educational methods.
Art therapy reconciles emotional conflicts, music stimulates, relaxes, and
sedates, while drama therapy emphasizes creative theatre as a medium for
self-expression and playful group interaction. Social therapy is particularly
valuable when normal familiar relationships, social activities, and work
situations produce upsetting and self-defeating reactions in the client.
• Reassurance is a partner in all psychotherapies, even when there is purposeful
avoidance of pacifying consolation. The presence of the therapist serves to
conciliate the client, especially in severely upset clients who lack the capacity to
handle their anxiety through their own resources. Verbalized reassurance is
often given to clients, especially when doubts are voiced about their ability to
get well or when they are in the grip of fears conditioned by irrational thinking.
• Prestige suggestion is an ancient psychotherapeutic technique that plays a
crucial role in every psychotherapeutic relationship. It involves the client
selecting specific aspects of the therapist's message or suggestion to respond to,
which can be used deliberately or in the form of directives. Autosuggestion is
another form of prestige suggestion directed at the self, where the client uses
their internalized image as a dissociated surrogate to deliver commands to
themselves.
• Persuasion is another technique used by therapists to persuade clients to revise
their views and life philosophies. This technique is based on the belief that
clients have the power to modify their pathologic emotional proneness through
force of will or common sense. The aim is to build self-confidence and make the
client their own master.
• Pressure and coercion are authoritative measures that stimulate the client
towards fruitful actions. These measures are useful for dependent personalities
who refuse to face life under any other circumstances than being forced to
comply. Injunctions may be of value for immature individuals who tend to act
out their problems, those who habitually shy away from reality, and those who
refuse to take resolute action by themselves. Therapeutic pressure may be
exerted in the form of assigned pursuits, but it should only be used as a
temporary measure in critical situations.
• Confession and ventilation are important techniques in psychotherapy, as they
help release pent-up feelings and emotions and expose inner painful elements
to objective reappraisal. Verbalization of fears, hopes, ambitions, and demands
can provide relief, especially when subjected to an uncritical and sympathetic
appraisal. Confidence in the therapist secures an ally to help the client tolerate
and reveal inner secrets.
Tactics of S.P.
● Structure of the treatment situation: - Flexibility is the rule, in terms of
duration, frequency and setting. Methods of payment can vary depending on
the needs and comfort of the client
● Activation of transference- Transference is maintained at dilute and
unconscious level and feedback is offered promptly, as soon as possible. Reality
information about changes in the frame to reduce transference distortion is
offered. Appropriate personal information and opinion are offered. Defenses are
maintained against awareness and content of transference feeling or wishes.
Negative transference is discouraged
● Level of Consciousness - Focus is on the issues that are already in the conscious
awareness of the client. Identification with the therapist in encouraged. The
therapist may provide personal information and responses, may advise or
suggest ways of problems solving, may encourage imitation of the therapist
judgment and clues and may provide active alternative understanding of the
situation.
● Management of resistance and defenses - Defenses are in general unchallenged
and maintained or even strengthened to promote more comfortable adaptation.
If the resistance and the defenses used by the client threaten the client's
external adjustment or therapeutic relationship, new and substitute defenses
are suggested.
● Catharsis and abreaction - Emotional responses and affects associated to
already conscious memories or trauma are encouraged and are responded to in
whatever way seems appropriate.
● Adaptation to the client’s character organization - Therapist seeks to intervene
in ways familiar and compatible with the client’s overall character structure,
thereby striving to avoid confrontation or stress in terms of how the client
characteristically interacts in various situation.
● Management of Regression Reinforcement - Regression is minimized and
where ever possible it is reversed
● Reinforcement - Transference relationship is used to achieve whatever goals
have been set
● Use of therapist as Alter ego - Therapist may at times serve as an alter ego
when the client is unable to carry out a particular activity, intervention, effort or
pattern of behavior to satisfy or fulfill his or her needs. In such situation
therapist might act for the client by intervening in various situations, with
people with whom the client is unable to maintain or establish his/her own
interest and may simultaneously present a model of how one can go about
resolving such problem.
● Use of medication - Medications are commonly used as an adjunct for the
control of symptoms and alleviation of distressing behavior.
● Insight - Insight is considered less important
● Termination of therapy - Aim is more to consider interruption of therapeutic
contact, rather than termination
