SUPPORTIVE PSYCHOTERAPHY

Compiled by:

Michelle H (07120110086)

M. Alif Novaldi (07120110079)Preceptor:

dr. Dharmady Agus, SpKJDepartment of PsychiatryFaculty of Medicine Pelita Harapan UniversityDharmawangsa Sanatorium

2015

Table of ContentChapter 1

Introduction

Supportive psychotherapy is widely practiced and may in fact be the treatment provided to most psychiatric patients. Since the 1950s it has been recognized that psychotherapy should be systematically taught as an modality apart from analysis and that it shoud be conceptualized on its own terms, not as a lesser form of analysis. However, supportive psychoteraphy has seldom been taught. Paul Dewald (1971) described expresivve therapy and supportive therapy as the poles of the continuum of dynamic psychotherapies. Most patients receive a therapy that incorporates both supportive and expressive elements. Chapter 2

PART 1 : Psychotherapy

I. Definition

Psychotherapy is the treatment for mental illness and behavioral disturbances in which a trained person establishes a professional contract with the patient and through definite therapeutic communication, both verbal and nonverbal, attempts to alleviate the emotional disturbance, reverse or change maladaptive patterns of behavior, and encourage personality growth and development. It is distinguished from other forms od psychiatric treatment such as somatic therapies (e.g psychopharmacology and convulsive therapies).II. Psychoanalysis and Psychoanalytic Psychotherapy These two forms of treatment are based on Sigmund Freuds theories of a dynamic unconscious and psychological conflict. The major goal of these forms of therapy is to help the patient develop insight into unconscious conflicts, based on unresolved childhood wishes and manifested as symptoms, and to develop more adult patterns of interacting and behaving.

A. Psychoanalysis Psychoanalysis is a theory of human mental phenomena and behavior, a method of psychic investigation and research, and a form of psychotherapy originally formulated by Freud. As a method of treatment, it is the most intensive and rigorous of this type of psychotherapy. The patient is seen three to five times a week, generally for a minimum of several hundred hours over a number of years. The patient lies on a couch with the analyst seated behind, out of the patients visual range. The patient attempts to say freely and without censure whatever comes to mid, to associate freely, so as to follow as deeply as possible the train of thoughts to their earliest roots. As a technique for exploring the mental processes, psychoanalysis includes the use of free association and the analysis and interpretation of dreams, resistances, and transferences. The analyst uses interpretation and clarification to help the patient work through and resolve conflicts that have been affecting the patients life, often unconsciously. Psychoanalysis requires that the patient be stable, highly motivated,verbal, and psychologically minded. The patient also must be able to tolerate the stress generated by analysis without becoming overly regressed, distraught, or impulsive. As a form of psychotherapy, it uses the investigative technique, guided by Freuds libido and instinct theories and by ego psychology, to gain insight into a persons unconscious motivations, conflicts, and symbols and thus to effect a change in maladaptive behavior.B. Psychoanalytically oriented psychotherapy

Based on the same principles and techniques as classic psychoanalysis, but less intense. There are two types : (1) Insight-oriented or expressive psychotherapy and (2) supportive or relationship psychotherapy. Patients are seen one or two times a week and sit up facing the psychiatrist. The goal of resolution of unconscious psychological conflict is similar to that od psychoanalysis, but a greater emphasis is placed on day-to-day reality issues and a lesser emphasis on the development of transference issues. Patients suitable for psychoanalysis are suitable for this therapy, as are patients with a wider range of symptomatic and characterological problems. Patients with personality disorders are also suitable for this therapy. A comparison of psychoanalysis and psychoanalyticaly oriented psychotherapy is presented in Table 29-1.

In supportive psychotherapy, the essential element is support rather than the development of insight. This type of therapy often is the treatment of choice for patients with serious ego vulnerabilities, particularly psychotic patients. Patients in a crisis situation, such as acute grief, are also suitable. This therapy can be continued on a long-term basis and last many years, especially in the case of patients with chronic problems. Support can take the form of limit setting, increasing reality testing reassurance, advice, and help with developing social skills.

Basic Technique

The analysis of transference by the interpretation of resistance is important for the psychoanalytic psychotherapist. To promote the patients examination of the phenomena of transference and resistance, both the analyst and the therapist are guided by prin- ciples that establish a confidential, safe and predictable environ- ment geared toward maximizing the patients introspection and focus on the therapeutic relationship. The patient is encouraged to free associate, that is, to notice and report as well as she or he can whatever comes into conscious awareness (Tables 66.4 and 66.5). Therapeutic neutrality and abstinence are related concepts. Both foster the unfolding and deepening of the transference, as well as the opportunity for its interpretation. The psychoanalytic psychotherapist assumes a neutral position vis--vis the patients psychological material by neither advocating for the patients wishes and needs nor prohibiting against these. The patient is en- couraged in the therapeutic relationship to develop the capacity for self-observation. Neutrality does not mean nonresponsive- ness; it is nonjudgmental nondirectiveness.

Abstinence refers to the position assumed by the psychoan- alytic psychotherapist of recognizing and accepting the patients wishes and emotional needs, particularly as they emanate from transference distortions, while abstaining from direct gratifica- tion of those needs through action. Abstinence is a principle that guards against the therapists gratification at the patients ex- pense. For example, as the treatment experience deepens into a more consolidated transference neurosis, there may be a strong tendency by the patient to experience the therapist as the impor- tant person in the patients life around whom the characteristic conflictual issues are manifested. By maintaining a neutral and abstinent position with respect to the patients needs and wishes, the psychotherapist creates a safe atmosphere for the experiencing and expression of even highly charged affects, the safety required for the patients motivation for continued therapeutic work. The position held by the psychiatrist is neither sterile nor overstimulating and promotes the establishment of a meaningful therapeutic relationship.

The rule of free association dictates that the patient should verbalize to the best of her or his ability whatever comes into awareness, including thoughts, feelings, physical sensations, memories, dreams, fears, wishes, fantasies and perceptions of the analyst. Whereas at first glance this requirement appears to be unscientific, in fact, the psychiatrist and patient quickly come to appreciate that no thought or feeling is random or irrelevant but rather that all mental content is relevant to the patients emotional problems. Indeed, much productive therapeutic work is focused on those instances when the patient is not able to speak about what is on his or her mind.

Many psychoanalytic psychotherapists also use the tech- nique of dream interpretation, although recently there may be less emphasis on this. Freud placed great emphasis on the inter- pretation of dreams because he discovered that such a technique provided insights into the working of the unconscious. In a simi- lar fashion, slips of the tongue, jokes, puns and some types of forgetfulness are attended to carefully by the therapist because they are nonsleep activities that also provide insight into the pa- tients unconscious mental processes. Good technique does not necessarily include pointing out to the patient these events each time they occur, for they may often be a source of intense embar- rassment. Rather, the slips are noted as helpful data in assessing the patients inner thoughts.

All of these techniques are embedded in a unique manner of listening to the patients verbalizations within the context of the treatment situation. In particular, two related but specific compo- nents initially attributed to the listening process are worthy of note. First, the concept of the evenly hovering or evenly suspended attention implies that listening to the patient requires of the thera- pist that he or she be nonjudgmental and give equal attention to every topic and detail that the patient provides. It also embraces the notion that the effective therapist is one who can remain open to her or his own thoughts and feelings as they are evoked while listening to the patient. Such internal responses often supply im- portant insights into the patients concerns. Secondly, empathic listening is of equal importance to both parties. Empathy permits the patient to feel understood, as well as provides the therapist with a method to achieve vicarious introspection. Indeed, one of the major contributions of self-psychology has been the identifi- cation of empathic listening and interpretation (the immersion by the therapist into the subjectivity of the patients experience) as basic to the methodology of psychoanalysis and psychoanalytic psychotherapy (Kohut, 1978, 1971). Interferences to successful empathic listening are often the product of countertransference reactions, which should be suspected whenever, for example, the therapist experiences irritation, strong erotic feelings, or inatten- tion during a treatment session.

Psychoanalytic psychotherapy helps by permitting the patient to become increasingly conscious of troublesome feelings, conflicts and wishes that heretofore had remained out of awareness and that produced unhappiness by promoting repetitive self-defeat- ing behaviors, that is to gain insight.

Whereas insight has always been valued as a goal, insight by itself is insufficient. The process whereby insight is acquired is a lengthy and arduous one that is inextricably linked with the recall of painful affects, memories and traumatic experiences. For treatment to be effective, there must be both cognitive and affective experiences for the patient. Neither a purely intellectual nor a purely cathartic experience is likely to result in relief or be- havioral change. The support provided by the treatment relation- ship, which includes commitment, respect, reliability, honesty and care, is a powerful factor in the curative process. It is this atmosphere that makes bearable the emotional pain that accom- panies the healing of the wounds first experienced in isolation, so often inflicted by the first objects of the patients love, need and trust. All of these considerations are central to psychoanalytic psychotherapy as well.

The concept of working through is helpful in appreciat- ing the often lengthy and complex psychotherapeutic processes. Working through is that stage or aspect of treatment characterized by repeated identification of reenactment and reliving of earlier experiences through confrontation, clarification, and interpreta- tion of resistance and transference that ultimately promotes the patients self-awareness. In effect, the working through process frees the patient from the position of being at the mercy of uncon- scious conflicts and fears that have compromised interpersonal relationships and achievement. This is accomplished not only through the analysis of the transference but also of current inter- personal relationships outside of the psychotherapy. Ultimately, a thorough understanding of the transference and of current re- lationships can permit the patient to appreciate their relationship to important early experiences and ultimately to ameliorate the influence of the past on the present.Therapeutic Alliance

A great deal of research in the outcome of psychoanalytic psycho- therapy has focused on the importance of the therapeutic alliance (Docherty, 1985). Increasing appreciation for the role of supportive factors, such as the rapport between the patient and therapist that constitutes the therapeutic relationship, has balanced the earlier and more narrowly defined position that attributed thera- peutic success exclusively to insight resulting from specific inter- pretive activity. The clinical consequences of this appreciation of the helpfulness of nonspecific factors have been the psychoana- lytic psychotherapists paying much greater attention to the ini- tial phases of engaging the patient in psychotherapy and a greater respect for those positive and negative factors that the therapist brings to the working relationship. Currently, approaches to psy- choanalytic psychotherapy hold that the psychiatrists person- ality and interventional technique have equal influence on the therapeutic process. In essence, the contemporary view is more dyadic, and places greater importance on the contributions of the therapist (both the conscious and the unconscious), as well as of the patient with respect to progress and impasse in the psycho- therapeutic process.

Contemporary psychoanalytic psychotherapists still em- phasize elucidation of the unconscious, especially within the transference, and still use interpretation as a primary clinical intervention, but recognizes more fully the important role of the mutual emotional engagement of therapist and patient and the curative role of this relationship in addition to other supportive factors. They adhere to a much broader perspective on human development and psychiatric disorders. Psychological problems can result not only from early intrapsychic conflict but also from developmental deficits or failures as well as from psychological trauma (Table 66.6).

The Difference between Psychoanalytic Psychotherapy and Psychoanalysis

The answer to this question has occupied many researchers and psychiatrists throughout the last 50 years. Efforts have been made continually not only to elucidate the differences between the two treatments but, more important, to define the underlying princi- ples of psychoanalytic psychotherapy. Whereas some prefer defi- nitions of psychoanalysis and psychotherapy as distinct separate entities, it is more useful to many psychiatrists to conceptualize psychoanalysis and psychoanalytic psychotherapy as residing on a therapeutic continuum. As discussed, there is much in the conduct of psychoanalytic psychotherapy that has been borrowed from psychoanalysis. Free association, clarification and interpre- tation in psychoanalytic psychotherapy are such examples. The centrality of transference is another, although early psychiatrists and researchers advocated that transferences were to be recog- nized and acknowledged in psychoanalytic psychotherapy and managed rather than interpreted so that patients were not subject to the intense therapeutic regressions characteristic of psy- choanalysis. Today, such a distinction regarding the approach to transference in psychoanalytic psychotherapy is less rigid.

On the other hand, certain supportive and more directive techniques, such as greater activity of the therapist through focusing the patient on specific current problems and relationships, reassuring and affirming the patient, and the giving of advice, are used much more in psychoanalytic psychotherapy than in psychoanalysis. Therefore, the adherence to the therapists neu- trality is less strict, and as a result, there is often but not always less frustration for the patient in psychoanalytic psychotherapy. The length of treatment may not distinguish the two approaches, but the frequency of sessions (four or five per week) and the use of the couch, however, are characteristic of psychoanalysis (see Table 66.7).

Overall, it is fair to say that psychoanalytic psychotherapy : Places greater emphasis on the here and now in terms of the patients current interpersonal relationships and experiences outside of the therapy; whereas in psychoanalysis, there is greater emphasis on the experiences within the analysis and

the relationship between analyst and analysand; Incorporates, more than does psychoanalysis, vari- ous other techniques from other dynamic and behavioral

psychotherapies; Emphasizes the usefulness of focusing on current (dynamic)

problems and less on genetic issues; and Establishes more modest goals of treatment.

The last point is particularly important in that it facilitated the development of brief dynamic psychotherapies which address focal problems generally in up to 20 sessions.

III. Behavior Therapy Behavior therapy focuses on overt and observable behavior and uses various conditioning techniques derived from learning theory to directly modify the patients behavior. This therapy is directed exclusively toward symptomatic improvement, without addressing psychodynamic causation. Behavior therapy is based on the principles of learning theory, including operant and classical conditioning. Operant conditioning is based n the premise that behavior is shaped by its consequences ; if behavior is positively reinforces, it will increase; of it is punished, it will decrease; and if it elicits no response, it will be extinguished. Classical conditioning is based on the premise that behavior is shaped by being coupled with or uncoupled from anxiety-provoking stimuli. Just as Ivan Pavlovs dogs were conditioned to salivate at the sound of a bell once the bell had become associated with meat, a person can be conditioned to feel fear in neutral situations that have come to be associated with anxiety. Uncouple the anxiety from the situation, and the avoidant and anxious behavior will decrease.

Behavior therapy is believed to be most effective for clearly delineated, circumscribed maladaptive behaviors (e.g phobias, compulsions, overeating, cigarette smoking, stuttering, and sexual dysfunctions). In the treatment of conditions that can be strongly affected by psychological factors (e.g hypertension, asthma, pain, and insomnia), behavioral techniques can be used to induce relaxation and decrease aggravating stresses (Table 29-2). There are several behavior therapy techiques.

IV. Cognitive-Behavioral Therapy

This therapy is based on the theory that behavior is determined by the way in which people think about themselves and their roles in the world. Maladaptive behavior is secondary to ingrained, stereotyped thoughts, which can lead to cognitive distortions or errors in thinking. The theory is aimed at correcting cognitive distortions and the self-defeating behaviors that result from them. Therapy is on a short-term basis, generally lasting for 15 to 20 sessions during a period of 12 weeks. Patients are made aware of their own distorted cognitions and the assumptions on which they are based. Homework is assigned; patients are asked to record what they are thinking in certain stressful situations and to ascertain the underlying, often relatively unconscious, assumptions that fuel the negative cognitions. This process has been referred to as recognizing and correcting automatic thoughts. The cognitive model of depression includes the cognitive triad, which is a description of the thought distortions that occur when a person is depressed. The triad includes (1) a negative view of the self, (2) a negative interpretation of present and past experience, and (3) a negative expectation of the future. Cognitive therapy has been most successfully applied to the treatment of mild to moderate nonpsychotic depressions. It also has been effective as an adjunctive treatment in substance abuse and in increasing compliance with medication. It has been used recently to treat schizophrenia.

V. Family Therapy

VI. Interpersonal Therapy

VII. Group Therapy

VIII. Couple and Marital Therapy

IX. Dialectical Behavior Therapy

X. Hypnosis