Class 6 Flashcards
What is supportive psychother
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.
self esteem
sense of efficacy, confidence, hope and self regard
ego fn
relation to reality, thinking, defences, affect and impulse regulation, synthetic fn
adaptative skills
actions taken in response to reasonable assessment of the situation
triangle of conflict
anx, defense, wish/need/feeling
In triangle of conflict, supportive goals are to
reduce anxiety and strengthen adaptive defenses, generally without pursuing the wish or feeling
Triangle of person
therapist, parents, current others
In triangle of person, supportive goals
include emphasizing the real relationship with the therapist, and addressing issues with current figures in the patient’s life.
Theoretical Principles: CBT
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
Theoretical Principles: Learning Theory
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
Useful concepts from research in adult education:
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
Indications
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.
Contraindications
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
Frame
Flexible frequency and duration
Duration may be short or intermittent long term; single session or lifelong
Patient and therapist are face-to-face
Therapeutic Stance
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
General Principles for Interventions
“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
Beginning Phase
Diagnosis Suitability – no contraindications Alliance Formulation of patient’s presenting problems Collaborative goal-setting
Beginning Phase: Alliance
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
Beginning Phase: Formulation
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
Beginning Phase: Goals
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.
Middle Phase
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
Termination
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
Interventions-Alliance and Esteem-Building
Reflecting thoughts and emotions
Empathizing
Praise
Encouragement
Interventions-Anxiety-Reducing
Signposting
Naming the problem
Reassurance and normalizing
Interventions-Skills-Building
Advice/suggestion Teaching Reframing Modeling adaptive behaviour Anticipatory guidance
Interventions-Awareness-Expanding
Clarification
Confrontation
Interpretation
Reflecting thoughts and emotions
therapist functions as an interested and nonjudgmental witness of patient’s experiences, feeding back his or her understanding of them
Empathizing
demonstrates an attunement with the patient’s internal state; contributes to patient’s sense of being meaningfully known
Praise
express praise abundantly, but avoid false praise, and seek feedback from the patient to ensure the praise is meaningful
Encouragement
may entail stimulating patient to action, e.g. re: hygiene, or giving the patient hope
Sharing the agenda (signposting)
therapist shares rationale with patient, warns or asks permission re: anxiogenic questions or topics
Naming the problem
enhances patient’s sense of control; part of psychoeducation
Reassurance and normalizing
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.
Advice/suggestion
the major challenge is knowing when to move from giving advice to helping patient develop internal or extra-therapeutic external resources
Teaching
psychoeducation based on either technical knowledge or the therapist’s position as a rational, informed person familiar with the unwritten rule book of life
Reframing/cognitive restructuring
try to avoid argument or contradiction; ideally the patient is encouraged to think for him- or herself of alternative possibilities
Modeling adaptive behaviour
consistently demonstrate adaptive, reasonable and organized thinking and behaviour
address errors with honesty, humility and resilience
Anticipatory guidance
Consider potential obstacles and strategies to overcome them in advance; can include role play or rehearsal
Clarification
Summarize, paraphrase, or organize information to reflect back to patient to help them appreciate the significance of what they have said
Confrontation
Directing attention to inconsistencies in behavior or conflicting goals and motivations
Interpretation
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.
Alliance: Transference
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
Alliance: Countertransference
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.
Alliance: Devaluing
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
Alliance: Resistance
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)
Alliance: Self-disclosure
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
