Class 6

Question 1

What is supportive psychother

Answer 1

A tri that uses direct measures to ameliorate sx and prevent relapse by maintaining, restoring or improving:
self-esteem, ego functions, adaptative skills.
Form of psychodynamic psychotherapy.
Common factors” therapy; providing a “holding environment” and creating a positive therapeutic alliance
A psychoanalytically-informed treatment approach with more limited objectives than psychoanalysis. Goal was to help seriously ill patients cope with symptoms or relatively healthy patients deal with transient problems, i.e. patients on the “left side” of the psychotherapy/impairment continuum. Expressive for least ill pts.

Question 2

self esteem

Answer 2

sense of efficacy, confidence, hope and self regard

Question 3

ego fn

Answer 3

relation to reality, thinking, defences, affect and impulse regulation, synthetic fn

Question 4

adaptative skills

Answer 4

actions taken in response to reasonable assessment of the situation

Question 5

triangle of conflict

Answer 5

anx, defense, wish/need/feeling

Question 6

In triangle of conflict, supportive goals are to

Answer 6

reduce anxiety and strengthen adaptive defenses, generally without pursuing the wish or feeling

Question 7

Triangle of person

Answer 7

therapist, parents, current others

Question 8

In triangle of person, supportive goals

Answer 8

include emphasizing the real relationship with the therapist, and addressing issues with current figures in the patient’s life.

Question 9

Theoretical Principles: CBT

Answer 9

Supportive psychotherapy makes frequent use of CBT techniques, and shares the idea that behaviors and feelings are linked to the nature and characteristics of thinking
Focus in supportive psychotherapy is at the level of automatic thoughts more than schemas

Question 10

Theoretical Principles: Learning Theory

Answer 10

Supportive psychotherapy interventions emphasize teaching and learning skills and knowledge
Encoding and processing of information is affected in a number of psychiatric conditions as well as in traumatic or stressful situations
Learning theory suggests that we should monitor patient’s ability to encode information within and between sessions and adjust interventions accordingly

Question 11

Useful concepts from research in adult education:

Answer 11

Collaboration in goal-setting enhances motivation and sense of ownership
Resource identification: want the pt to become independent in divising their own strategies in getting resources outside the therapy
Self-assessment
Linkage of new information with pre-existing knowledge (‘interpretation’)
Generation: develop skills to develop own solutions on their own

Question 12

Indications

Answer 12

Some degree of motivation and ability to form therapeutic alliance

Acute crisis in a usually well-functioning person, with breakdown of usual coping

Chronic severe pathology, with fragile or deficient ego functioning

Cognitive deficits

Major physical symptoms

Psychologically unmotivated or lacking psychological-mindedness.

Question 13

Contraindications

Answer 13

Rarely contraindicated as such. Perhaps not sufficiently beneficial to better-functioning patients. Some authors have suggested that supportive psychotherapy should be the default psychotherapy offered to all patients.

“Organic mental disorders”, e.g. delirium, intoxication, late-stage dementia

Help-rejecting complainers, who often get worse during treatment as they are not invested in becoming more adaptive

Malingering or psychopathy

Conditions for which formal CBT has shown empirical superiority; panic disorder, OCD, bulimia nervosa (relative contraindication; use CBT if available and patient interested

Question 14

Frame

Answer 14

Flexible frequency and duration

Duration may be short or intermittent long term; single session or lifelong

Patient and therapist are face-to-face

Question 15

Therapeutic Stance

Answer 15

Active and empathic
Oriented to present reality (rather than projections from the past)
Affectively responsive (rather than neutral)
“Be yourself”
“Be real”
Conversational
Self-revealing

Question 16

General Principles for Interventions

Answer 16

“Do not say everything you know, only what will be helpful” (Douglas)

“Be like a good parent” (Misch): keep in mind the goal of fostering individuation and autonomous functioning

Be honest and realistic

Link your interventions to evidence from the patient’s own history or a psychoeducational point (avoid “empty” interventions)

Do not support maladaptive or exploitative behaviours

Question 17

Beginning Phase

Answer 17

Diagnosis
Suitability – no contraindications
Alliance 
Formulation of patient’s presenting problems
Collaborative goal-setting

Question 18

Beginning Phase:
Alliance

Answer 18

Maintaining a positive therapeutic alliance is essential.
Monitor how patient is feeling about him/herself, the therapist, and the therapy.
If a rupture in the alliance is detected:
First step: rapidly repair in a validating, direct and practical manner
Second step (if necessary): move to explore symbolic or transference issues

Question 19

Beginning Phase: Formulation

Answer 19

No specific theory; may use concepts from psychodynamic, CBT, interpersonal or any other relevant theory to complete a biopsychosocial formulation

Focus of formulation is on organizing and specific goals of therapy

Question 20

Beginning Phase: 
Goals

Answer 20

Organizing goals:

Suppress or control symptoms

Maintain or improve self-esteem

Assist ego function and strengthen adaptive defenses

Maximize adaptive capacities

Set realistic and specific treatment goals in collaboration with the patient in addition to the organizing goals of the therapy

Focus is on conscious external problems and conflicts. Gaining insight and addressing personality distortions are not goals of supportive psychotherapy.

Question 21

Middle Phase

Answer 21

Continue to monitor and optimize the alliance
Middle phase may be indefinite, with intermediate goals set as needed
Balance shifts flexibly between therapist-directed (psychoeducational and skills-building) and patient-driven (i.e. patient’s acute concerns) processes
Trajectory toward patient’s autonomous use of new skills and knowledge

Question 22

Termination

Answer 22

Fundamental position is that it is the patient’s right to stop therapy when he or she wishes, though if therapist feels this is a maladaptive decision it may be gently explored
Otherwise, therapy ends when goals have been achieved
Focus is on summarizing gains and planning for patient’s self-sufficiency
Mourning process and loss of therapist are not a focus; patient is invited to return should the need arise

Question 23

Interventions-Alliance and Esteem-Building

Answer 23

Reflecting thoughts and emotions
Empathizing
Praise
Encouragement

Question 24

Interventions-Anxiety-Reducing

Answer 24

Signposting
Naming the problem
Reassurance and normalizing

Question 25

Interventions-Skills-Building

Answer 25

Advice/suggestion
Teaching
Reframing
Modeling adaptive behaviour
Anticipatory guidance

Question 26

Interventions-Awareness-Expanding

Answer 26

Clarification
Confrontation
Interpretation

Question 27

Reflecting thoughts and emotions

Answer 27

therapist functions as an interested and nonjudgmental witness of patient’s experiences, feeding back his or her understanding of them

Question 28

Empathizing

Answer 28

demonstrates an attunement with the patient’s internal state; contributes to patient’s sense of being meaningfully known

Question 29

Praise

Answer 29

express praise abundantly, but avoid false praise, and seek feedback from the patient to ensure the praise is meaningful

Question 30

Encouragement

Answer 30

may entail stimulating patient to action, e.g. re: hygiene, or giving the patient hope

Question 31

Sharing the agenda (signposting)

Answer 31

therapist shares rationale with patient, warns or asks permission re: anxiogenic questions or topics

Question 32

Naming the problem

Answer 32

enhances patient’s sense of control; part of psychoeducation

Question 33

Reassurance and normalizing

Answer 33

must be honest, linked to an understanding of the patient’s unique situation, and backed up by therapist’s expert knowledge, dependable common knowledge, or evidence from patient’s own history
do not reassure in order to alleviate fear of uncertainty, rather teach the patient strategies to cope with those fears.

Question 34

Advice/suggestion

Answer 34

the major challenge is knowing when to move from giving advice to helping patient develop internal or extra-therapeutic external resources

Question 35

Teaching

Answer 35

psychoeducation based on either technical knowledge or the therapist’s position as a rational, informed person familiar with the unwritten rule book of life

Question 36

Reframing/cognitive restructuring

Answer 36

try to avoid argument or contradiction; ideally the patient is encouraged to think for him- or herself of alternative possibilities

Question 37

Modeling adaptive behaviour

Answer 37

consistently demonstrate adaptive, reasonable and organized thinking and behaviour
address errors with honesty, humility and resilience

Question 38

Anticipatory guidance

Answer 38

Consider potential obstacles and strategies to overcome them in advance; can include role play or rehearsal

Question 39

Clarification

Answer 39

Summarize, paraphrase, or organize information to reflect back to patient to help them appreciate the significance of what they have said

Question 40

Confrontation

Answer 40

Directing attention to inconsistencies in behavior or conflicting goals and motivations

Question 41

Interpretation

Answer 41

Bringing avoided material into awareness if doing this will help with the goals of the therapy. Timing and level of interpretation should be as non-anxiogenic as possible. “Strike while the iron is cold”; after the affect has settled. Inexact, incomplete and intellectualized interpretations are best.
*Used sparingly, if ever.

Question 42

Alliance: Transference

Answer 42

Transference and countertransference are present and noted but are “managed” rather than interpreted
Positive feelings are encouraged, even if moderately unrealistic, as this can promote and protect the alliance

Question 43

Alliance: Countertransference

Answer 43

Countertransference can be used cautiously to help patient understand his impact on others if other methods have not succeeded, but this should be discussed in supervision beforehand. The focus should be on using the information to problem-solve and improve interpersonal skills.

Question 44

Alliance: Devaluing

Answer 44

Being unreasonably criticized or devalued can be painful and evoke irritation, frustration and helplessness
The adaptive response of the therapist is to model healthy, adult behaviour by restraining himself from either capitulation or counterattack
Supervision is essential

Question 45

Alliance: Resistance

Answer 45

Join the resistance’: empathic intervention
Reduce anxiety: explain rationale for interventions
Reframe resistance as healthy self-assertion; be more accepting of patient’s decisions and need for control
Respond to silence and distancing by selecting an issue to discuss (but monitor for misalliance)

Question 46

Alliance: Self-disclosure

Answer 46

Judicious self-disclosure can be used if there is a clear therapeutic purpose. It may serve one of the following purposes: 
Modeling and educating
Promoting alliance 
Minimizing transference
Validation of reality
Fostering patient autonomy