An option for challenging patients
Psychotic disorders. Although it may seem intuitive that psychotic conditions are a contraindication for psychotherapy, patients with schizophrenia and other psychotic disorders often benefit immensely from supportive psychotherapy. A supportive therapist’s guiding influence can help psychotic patients cope with fractured social and family life, struggles with independence, loneliness, frequent disturbances of reality, stigmatization from society, and difficulty with decision-making.
During a patient’s acute psychotic episodes, you can draw on the therapeutic relationship you have established, strongly advising the patient to accept treatment when he or she is paranoid and rejecting help. In such situations, you might say, “Joe, you know me. You know that in the past I have helped you get through some tough times. You are going to have to trust me that you need this medicine now, even if you don’t want to take it.”
Borderline personality disorder. Supportive psychotherapy’s emphasis on reducing anxiety and nurturing a therapeutic relationship makes it a good treatment for patients with borderline personality disorder. The focus on adaptive skills, self-esteem, and higher order defenses—such as repression, sublimation, rationalization, intellectualization, inhibition, displacement, and humor—is particularly suitable for self-injurious and suicidal patients.11
In addition, dialectical behavior therapy is congruent with supportive psychotherapy.12 I have found it useful to let patients know I am experienced and strong enough to undergo therapy with them and can live with the chaos of their lives. This often comforts patients with borderline personality disorder, as their internal state conveys a sense of destruction not only for them but anyone close to them. From a psychoanalytic perspective, conveying a sense of safety is a core healing component of supportive therapy.13
Substance abuse. A lack of treatment response and therapist burn-out are recurrent problems when treating patients with substance abuse.14 I have found it useful to “stretch” my treatment timeline—for example, by measuring change in years instead of months—so that I don’t continually feel unsuccessful. This allows me to focus not on the patient’s immediate sobriety but instead on the supportive relationship, especially on helping the patient address his or her sense of guilt and failure, which frequently underpins substance abuse.
Helping your patient to reframe his or her substance abuse as “bad choices” instead of the actions of a “bad person” is essential. Accompanying the patient to an Alcoholics Anonymous meeting—“I’ll go with you to the first one, after that it is up to you”—can be a powerful intervention with lasting benefits.
Related resources
- Werman DS. The practice of supportive psychotherapy. New York: Brunner/Mazel; 1984.
- Winston A, Rosenthal RN, Pinsker H. Introduction to supportive psychotherapy. Arlington, VA: American Psychiatric Publishing, Inc; 2004.
- Pinsker H. A primer of supportive psychotherapy. Hillsdale, NJ. The Analytic Press; 1997.
- Imipramine • Tofranil
Dr. Battaglia is a consultant to Eli Lilly and Company.