Supportive Psychotherapy for Medical Students

Adapted and excerpted from Basic Principles of Supportive Psychotherapy American Psychiatric Press Inc.

What is Supportive Psychotherapy?

Supportive psychotherapy is a kind of therapy most physicians can offer their patients. It aims to improve symptoms and maintain, restore or improve self-esteem and skills. In formal therapy sessions, supportive psychotherapy may involve examination of relationships (to the therapist and others) and examination of patterns of emotional response or behavior. In less formal settings such as a primary care office, supportive psychotherapy may mean an expression of interest, attention to concrete services, encouragement and optimism. Some regard this not so much supportive psychotherapy as "supportive contact" In the role of medical student and later as a resident and an attending physician, you will have the opportunity to provide both formal treatment and the less formal supportive contact.

There are many types of "flavors" of psychotherapy, many of which are effective. Effective therapies sometimes seem radically different but have a common element among them that makes them effective: the therapeutic alliance. The therapeutic alliance is the connection that the patient feels with the physician, as well as the patient's belief that the physician is aligned with the patient's goals, has respect for the patient and holds the patient in positive regard. It appears that a very good therapeutic alliance is one of the strongest predictors of good outcome from many kinds of treatments, including medication treatment of depression.

An important element of the supportive psychotherapy relationship is that it exists solely to meet the needs of the patient. The physician's gratification must come from professional satisfaction and a job well done and not from the patients gratitude or from the patient being an audience. Similarly, treatment planning considers what the patient wants to accomplish. Boundaries are another important consideration. Boundaries are best thought of as staying within the professional role. The professional physician does not advise the patient on how to vote, where to vacation or how to decorate a bedroom as these are private or personal opinions. The interaction between the patient and the physician may be friendly but the two individuals do not become friends. Physical canted is of course prohibited.

One model for a successful supportive therapist is that of a "good parent." (Misch 2000). The physician takes on many parental roles including comforting, soothing, encouraging, containment, limit setting and confronting self-destructive behaviors. This role also includes encouraging growth, autonomy and self-sufficiency.

Supportive psychotherapy addresses only problems and conflicts that the patient is aware of. Other types of psychotherapy rely on less direct measures, such as identifying unconscious conflicts. Supportive psychotherapy looks at abstract entities such as defense mechanisms only when they seem maladaptive. An example of this would be a physician addressing denial in a patient's illness as follows:

Physician: Mrs. Wells, I think it's time for us to take a hard look at your blood sugars.

Patient: I'm not worried—they run a little high in my family and we're none the worse for it.

Physician: I know you see things that way, but it's my job to sometimes show you how I see it from a doctor's point of view. I think the blood sugars are far beyond the normal range and might be causing you problems in ways you may or may not notice.

Patient: I think I'd notice.

Physician: It's human nature to sometimes not see things. Let's do this. There's a blood test that gives us a good idea on blood sugar levels over a span of time. We'll check that, look at the test result and go from them.

Techniques of Supportive Psychotherapy

Praise

Abundant praise is a good supportive technique. It can be sprinkled into the conversation like salt from a salt shaker. Praise may reinforce accomplishments or positive changes in behavior. Obviously, in order to be meaningful as a supportive comment, the praise must be accurate and sincere. In order to ensure that the praise is on target, the physician therapist may seek patient feedback by asking, "What do you think? Were you pleased with yourself?" It may be useful to complement a patient for persisting with a difficult project or a difficult topic. The best praise is reinforcement of the patient's steps towards achieving his or her stated goals.

Patient: I took my insulin every day last week.

Physician: Good. You said you were going to do this—not skip a single dose—and you did it. What do you think?

Physician: Wow, look at this baby girl's weight—she's regained all her birth weight plus two ounces. You guys are doing a fabulous job.

Reassurance

Reassurance is a familiar tactic in general medicine. Like praise, reassurance must be honest. As with praise, the patient must believe that the reassurance is based on an understanding of his or her unique situation. Reassurances given before the patient has detailed his or her concerns are likely to carry little weight with the patient. The physician must limit reassurance to areas in which she or he has expert knowledge or dependable information. For example, although it is reasonable to reassure a patient about the immediate side effects of a new medication, it is less reasonable to reassure the patient about long-term effects of this new medication. It is never correct to guarantee a certain treatment is going to be completely successful. What we can reassure the patient about is our unconditional concern. We can reassure patients with chronic illnesses that regardless of the course of the illness we will continue to provide care. In the face of fear about the unknown or the unknowable, such as questions of death and dying, the role of the physician is to help find strategies for dealing with the fearfulness and not to reassure it away.

Patient: If this is cervical cancer, will I be able to have another baby? Will I die from it?

Physician: It's too soon to know any of that. What I know, and I think you do too, is that you and I have worked together at other times, like during your first pregnancy. We took it one day at a time, kept in touch, and checked everything out. This is the same thing. We don't have answers now, but we will take it one day at a time, keep in touch and check it out. Let's set up an appointment so we can go over the blood test results after you go to the lab next week. And we will take it from there.

Patient: Whenever I go anywhere, I have this fear that I'm going to lose control.

Physician: I don't think you will lose control. You have had this fear for a long time and you have always been able to maintain good self-control. (Reassurance based on the patient's history and reinforcement of adaptive behavior)

Normalizing

Normalizing is a form of reassurance. It allows the physician to reassure the patient that their experiences, thoughts, and feelings are not unusual or pathological. Reassurance and normalizing must not extend to pathological fears or relationships. The physician may use reassurance and normalizing from a position of authority as in the following examples.

Physician: It might be interesting for you to know that 40% of college students experience a classic panic attack during the four years of college.

Patient: Maybe it's all in my head.

Physician: Everyone from time to time wonders that. It's what we do when we don't have the answers about these kinds of symptoms.

Encouragement

Encouragement has a major role in general medicine and rehabilitation. For patients with severe illnesses such as chronic schizophrenia, the physician may encourage the patient to maintain hygiene and to interact with other people.

Higher functioning patients may get encouragement to achieve educational or professional goals. Changes in behavior often require small steps. Patients may discount small steps, seeing each step is of no great importance. A skillful and supportive physician will identify tasks and activities that can be conceptualized as small steps. Encouragement can be powerful because people want to believe that their small efforts will lead to something larger. Exhortation is a more insistent form of encouragement.

Physician: I think it's great that you want to apply for courses at the community college. I think you should do it.

Physician: When we meet next time I'll be really interested in the specific small steps you took to control your anger in difficult situations.

Reframing

Reframing involves looking at something in a different light or different angle. Reframing can provide a welcome new way of looking at things.

Physician: I can see how you are disappointed. You didn't get to try out for the team with that sprain. I can also see how you might use this semester to focus on your academics instead of sports and get ahead there.

Physician: Yes, your son's behavior is challenging. He seems to be testing every limit in the book. At the same time it shows that he is a really secure kid and is right on track developmentally.

Physician: You do seem to be experiencing more anxiety. It looks like that's a result of trying new things.

Advice and Teaching

Advice is an important tactic for the physician to use in supportive psychotherapy. The challenge is knowing when to move from giving advice to helping patients find their own way to make good decisions. Advice is most meaningful when the patient sees it as connected to his or her goals and needs. Advice and teaching are most appropriate in areas where the physician is professionally expert. These topics would include medical and mental illnesses, normal human behavior, communications and healthy relationships.

Physician: This is the third time I've seen you for bronchitis in two months. I'm worried about the effect that cigarettes is having on your lungs and how well they can fight off infection. I think it's lime to enroll in a smoking cessation program.

Teaching is more important than advice. The effective physician therapist teaches the patient how to make the best health related choices.

Physician: As you get ready for your baby, I want to give you some information about breastfeeding. It's really the best thing for babies and for moms. Babies get great antibodies and nutrition. Moms get weight loss and less chance of post partum depression. Here are some handouts about breastfeeding facts. The nurses at the hospital are great at getting you started. Even though it can be tricky to get started, moms who breastfeed tell me they are so happy they chose it, and their babies are healthier too.

Language

Careful use of language might boost efforts to supped a patient's self esteem. Example of language that might be experienced as critical or confrontational are "I'm trying to get you to understand" and questions that begin with the words "Why…?" or "Why didn't you…?" These phrases are often experienced as attacks or rebukes. Alternatives to "Why?" are phrases such as "Can you explain how…?" or "Was there something about… that made you…?" (Pinsker 1997). Another practice which increases the positive relationship with the patient is choosing questions that elicit a positive response rather than a negative response. For example, it is better to ask an obese person "Do you find it difficult to exercise," than to ask "Do you like exercise?" It is better to ask the general open ended question than a closed question whenever passible.

Targets of Supportive Psychotherapy

Self Esteem

A physician can help the self-esteem of a patient by expressing acceptance, approval, interests, respect or admiration. Sometimes an accepting and interested physician is one of the few people in the patient's life who conveys acceptance and trust. The physician communicates interest in the patient by making it evident that he or she remembers their past conversations, remembers what the patient has said and is aware of the patients likes and dislikes. Acceptance is communicated by validating comments and the avoidance of arguing or criticizing. These supportive verbal interactions may be different than most of the patient's other relationships.

Physician: I recall you saying you always felt better about yourself after exercising.

Change

Change may concern specific behaviors, such as a low level of physical activity, cigarette smoking, skipping medications, or poor parenting choices. Sometimes simple advice is all it takes to get a patient to change his or her habitual behavior. In this case it is not necessary to do more. Often there are obstacles in the way of change that the patient does not bring up. If the physician wants to give useful advice, he or she must be familiar with some of the emotional problems that may be operating in the background One way to do this is to ask about a patient's feelings regarding the current problems in his or her behavior. Examining the patient's concerns or anxieties may lead to fruitful reassurance and problem solving.

Physician: Would it be OK if we did a pros and cons list of drinking? It might help you decide what's best for you.

Daily Life

For patients who are functioning at a low level, the physician therapist can ask about their dally routine as a way of finding out about opportunities for improving adaptive skills. It would be useful to know how the patient understands his or her condition and what feelings are related to that.

Physician: It would really help me understand your situation if you reviewed with me everything you do from the time you get up in the morning until you go to bed.

Relationships

The physician therapist should know about the important people in a patient's life. Higher functioning patients are likely to have important relationships and to think about their interactions with their significant contacts. Lower functioning patients may have an absence of meaningful relationships in their lives. It may be useful to ask patients about all of the contacts they have had in the last few days.

Physician: You mentioned three good friends. Tell me how often you have contact with them. What do the friends have in common?

Relapse Prevention

For patients with history of alcohol or drug abuse, relapse prevention is an important role for the supportive physician. Topics for the therapeutic conversation in these patients include:

  1. Identification of high risk situations
  2. Strategies for dealing with high risk situations
  3. Coping with negative emotional states
  4. Coping with interpersonal conflict
  5. Coping with social pressure
  6. Identifying relapse
  7. Anticipatory planning for dealing with relapse

Physician: Tell me about the triggers for drinking that you discovered over the holidays.