SUPPORTIVE PSYCHOTERAPHY

Compiled by:
Michelle H (07120110086)
M. Alif Novaldi (07120110079)

Preceptor:
dr. Dharmady Agus, SpKJ

Department of Psychiatry
Faculty of Medicine Pelita Harapan University
Dharmawangsa Sanatorium
2015

Table of Content

Chapter 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 gratification 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 relationship, 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 psychoanalytic 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 definitions 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 recognized 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 anxietyprovoking 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