Basic strategies of supportive therapy
Supportive therapy is the psychotherapeutic approach employed with the majority of mentally ill individuals. Even though supportive therapy incorporates many specific techniques from a wide variety of psychotherapy schools, it can be conceptualized as consisting of a more limited number of underlying strategies. The fundamental strategies that strengthen effective supportive therapy with mentally ill individuals are described below.
Strategy 1 – Formulate the case
Formulation is a focused brief conceptualization of the client or situation, based on the assessment. Some psychotherapist use case conceptualization instead of word formulation which is more neutral, which includes the whole range of biopsychosocial causes. Formulation is the therapist’s “theory of the case,” his or her understanding of what is “wrong” with the patient, and, as such, it serves as a roadmap for future therapeutic interventions.
Formulation of a case serves different purposes for the therapist. It allows the therapist to keep an eye on the horizon, which helps the patient as well as the therapist to make sure that they are moving in the right direction in the therapy process. It also helps the therapist to organize the key areas of problems and appropriate interventions. Another important purpose of formulation is that to develop hypotheses for further testing, which gives an idea about different dimensions of the problem and helps the therapist to plan more beneficial psychotherapeutic interventions.
To come to a true and deep understanding of another person does not happen immediately or easily; it takes time and patience, effort, trial-and-error and hypothesis testing, an open and interested mind. This means that the case formulation or conceptualization is never truly finished; it is, by definition, a work in progress, a fluid conceptualization that is altered as new information becomes available, old hypotheses prove unsupportive or unsustainable, and new aspects of the patient appear. The good therapist is always updating, amending, and cultivating his or her understanding of the patient and patient issue.
Strategy 2 – Be a good parent
Patient therapist relationship is the core of supportive psychotherapy. The supportive therapist constantly assesses the patient developmentally with respect to the latter’s strengths and deficits. When appropriate, the patient is comforted and soothed by the therapist; at other times, the therapist serves as a cheerleader, encouraging, nurturing, validating, praising, or congratulating the patient. On still other occasions, however, the patient must be confronted with respect to self-destructive behaviours. Appropriate protection, containment, and limit-setting are balanced with promotion of autonomy and independence. Similarly, the supportive therapist offers whatever helps needed, but at the same time encourages the patient’s growth and selfsufficiency.
In this therapy process therapist uses suggestions, advice, teaching to guide the patient’s thinking and behaviour; but like a good parent the main aim of the therapist is to help the patient to achieve his or her own goals rather than to substitute therapist’s life plan. Supportive therapist attempts to help the patient develop into an individual who is mature, in control, effective, and satisfied, just as a parent does with a child. Thus the analogy between the therapist–patient and parent–child relationships is important in supportive therapy.
Strategy 3: Foster and protect the therapeutic alliance
As we discussed earlier the relationship between the client and the therapist is the core of supportive psychotherapy. Even though there is some disagreement, in general the failure to foster and maintain a good working or therapeutic alliance between client and therapist is a predictor of poor psychotherapy outcome. This may happen in the case of poorly functioning patients, who may enter the therapeutic relationship with little trust, unrealistic expectations, and poor frustration tolerance. In the case of such clients, real and perceived mistakes, miscommunications on the part of therapist do not advantage a second chance, and such cases terminate the therapy prematurely.
Thus supportive therapist first goal is to attend the client throughout the therapy which will help to maintain the therapeutic alliance with the client. A positive therapeutic relationship in supportive therapy often directs the therapist in the role of a good parent. The therapist need not love the client, nor must agree with all of the client’s thoughts, beliefs, feelings, and behaviours. Therapist must respect the patient as an individual and couple this respect with compassion, empathy, and commitment. A good supportive therapist is friendly, flexible, creative, down to earth and practical, attempting to address everyday but important issues in client’s lives. A good therapist is able to do what the client needs without struggle. Finally, a competent supportive therapist believes in, and demonstrates, common sense common courtesy. This will help the therapist to foster and protect the therapeutic alliance.
Strategy 4: Manage the transference
Patients invariably have feelings about their therapists. When some of these feelings are “transferred” from early, important, childhood figures, to whom they were originally directed, onto the therapist, they are called “transference”. Transference by definition conveys a meaning that it is distortion of patient’s perception of the therapist, even though beginning therapist tend to think of transference as consisting of negative feelings toward the therapist, however transference may consist positive feeling as well.
Supportive therapists do not interpret the transference; they manage it. There are two key principles in the management of transference. First, positive transference is not interpreted; it is used. This means that in some cases client may view the therapist as supreme, omniscient, purely loving, and the like, the therapist does not correct this instead; the therapist uses the client’s trust in him or her to promote the aims of the supportive psychotherapy. The second element of management of transference relates to negative transference. Here also therapist put no effort to interpret the negative transference but the therapist tries to correct and confront it aggressively in the therapy; failure to deal with it results in premature termination of the therapy. That means in supportive psychotherapy a rapid and vigorous correction of negative transference is essential. In general, management of negative transference often necessitates the therapist to explicitly, and non defensively discuss what the therapist is doing and why such actions are being taken.
Strategy 5: Hold and contain the patient
The concept of holding and containing means a therapist’s efforts to be good parent by providing empathy, understanding, and setting appropriate limit. This also includes allowing the client to ventilate, express his or her thoughts and feelings.
Containing the client may require more aggressive interventions which include use of psychotropic medications and psychiatric hospitalisation. Both of these interventions should be used appropriately and therapist has to inform this to the immediate family members of the client as well. Even when containing the client, it is important to protect his or her autonomy as much as possible. Often the degree of containment will differ with the client’s situation and the stressors to which he or she is exposed.
Strategy 6: Lend psychic structure
This refers to the therapist’s role as an “auxiliary ego” for the client. In supportive therapy client is allowed to use the therapist’s presumably well working mind and psychological capacities in order to enhance his or her own psychic functioning in particular areas. That means client is encouraged to think like the therapist, who most likely represents a good role model for the client.
In the process of therapy therapist is, definitely, making a “loan”, rather than a permanent gift to most clients. Supportive therapist lends the client what psychic structure is needed at the time it is needed, but, along with, the therapist tries to promote the client’s growth, independence, and autonomy.
Strategy 7: Maximize adaptive coping mechanisms
The important goal of supportive psychotherapy is to increase client’s coping Supportive Psychotherapy skills, strengthen the adaptive coping styles and also decrease the use of maladaptive coping mechanisms. During the process of therapy therapist try to help the client to achieve healthy adjustment to the current stressors.
The supportive therapist can develop a client’s coping skills through education, repeated training and practice of specific skills for dealing with the stressors. Therapist’s lending ego and role modelling will encourage the client to enhance his or her coping mechanisms.
Strategy 8: Provide a role model for identification
Supportive therapist should provide himself or herself as a healthy role model with which a client can identify, but which does not mean that client has to live a life identical to that of therapist. Rather, client has to identify with a healthy psychological structure and function of the therapist.
In supportive psychotherapy therapist’s self – disclosure can play an important role, in that therapist need not reveal every personal details but he or she can offer himself or herself as an example or illustrative instance which also help to strengthen the therapeutic relationship.At the same time it is important that therapist should not present himself or herself as a perfect human being, which provides an opportunity for the client to learn from therapist’s mistakes as well as from success. Thus, the supportive therapist does not hold him or herself up as a perfect role model with whom the patient should identify, but rather presents as a decent mature human being.
Strategy 9: Decrease alexithymia
The term alexithymia means lack of awareness about one’s own feelings, the inability to recognise those feelings, this condition is highly disabling. Thus alexithymia is an appropriate target for supportive psychotherapy. In these conditions the goal of the therapy is to help the client to recognize, acknowledge, identify and label emotions. Client’s can attain this goal with the help of therapist by using some techniques such as making the list of their emotions or labelling their feeling by concentrating on somatic sensations associated with particular affect. This will help the client to identify their emotions, feelings and intervene it properly.
Strategy 10: Make connections
Psychologically impaired persons have difficulty to connect between their thoughts and feelings, between events and subsequent thoughts or feelings etc. Role of the therapist is to help the client to make connections between these which will affect the overall functioning and life satisfaction of the client. The basic theory behind this strategy is that thoughts and feelings are connected so by using cognitive approach. Client is shown how to identify the underlying automatic thoughts and core beliefs which lead to unpleasant
affects. This type of cognitive approach gives the client a greater sense of control over their feeling and thoughts by identifying the connections between these. Another method to make connections is confrontation, but it must be done thoughtfully, empathetically, and tactfully. The ultimate goal of the therapy is to change the locus of control from external to internal, heighted sense of responsibility, relief on the part of the client at actually having some control over the manner in which the world responds to him or her.
Strategy 11: Raise self-esteem
All psychotherapies attempt o raise client’s self- esteem by using different approaches. The healthiest way of raising self-esteem is by fostering an individual’s competency in real skills, so the most important is to take one step at a time and lead the client to success rather than failure. In supportive therapy this can be attained by using some techniques like behavioural rehearsal, roles play etc. The aim of the therapist by using these techniques is to enhance the client’s functional, adaptive behaviours through the mastery
of key skills, especially interpersonal and social skills, problem solving and coping strategies which help the client to decrease their anxiety and improve his or her self- esteem.
Strategy 12: Ameliorate hopelessness
Hopelessness in mentally ill individual is common and related to cognitive construction. Most of the clients have found only few options to solve their problems as a result of hopelessness. Reframing and cognitive behavioural therapy are the two psychotherapeutic approaches to intervene with this problem.
In supportive therapy therapist may take active steps to combat hopelessness through direct environmental manipulation such as helping a client to get disability status, get a new house, and find transportation. Hopelessness can also be restructured by elevation of client’s self-esteem, as we discussed previously. The most efficient way to do this is through the development of true competence or mastery of specific skills.
Strategy 13: Focus on the here and now
Supportive therapy never attempts to explore client’s childhood experiences and the effect of it, the primary focus of supportive therapy is the here and now issues (issues those concerning everyday life). Eg: How is the client getting along with the work? Is the client able to meet his or her daily needs? Is the client on regular medication? It is through these everyday details that the therapist has enough information to judge how the client is doing and what should be the focus of their work. In supportive therapy therapist commonly uses interpersonal as well as social skill training to help the clients function in a better way in everyday existence.
Strategy 14: Encourage patient activity
In supportive therapy therapist helps the client to become active to do rather than simply say or talk about. Ventilation is often beneficial in supportive therapy, but in long run, talking alone is not substitute for action. Only through the successful testing of new behaviours and skills or mastery of feelings of inadequacy will the client truly be convinced that he or she is capable in various areas. The setting of specific, concrete, achievable
behavioural goals also will play an important function to encourage the client’s activity.
In the therapy process therapist should assess the client’s current psychological state and capacities, the overall context, and the specific task under consideration, pondering if, when and how the client should undertake forward into a new or difficult experience. Subsequently, the therapist should work with the client to chart a specific plan of action, using different techniques.
Therapist also uses behavioural approaches such as behavioural rehearsal, role playing, relaxation, and imagery and so forth, are found to be helpful in helping the client to achieve his or her goals. Here also therapist serves as a cheerleader for the client’s efforts, even if such efforts are initially unsuccessful.
Strategy 15: Educate the patient and family
Education is an important role of supportive therapist. It helps the client to learn about his or her illness, symptoms, course of illness and prognosis. Education also includes impart knowledge about the warning signs of the illness, ways to prevent relapse, and medications for the illness. In the case of chronically mentally ill, it is important to educate about the illness to the patient’s family and other significant others in order to help the patient. At the same time therapist must respect the patient’s individuality, autonomy
Second educational role of the therapist has been discussed above, that is to educate the client with respect to reality testing, controlling impulses, making connections, and developing social and interpersonal skills. This knowledge empowers the client which leads to actual raise of self-esteem.
Strategy 16: Manipulate the environment
The supportive therapist, unlike other psychoanalyst, may intervene with other persons or agencies to help the patient, again with due regard for the patient’s autonomy and privacy. Hence, the supportive therapist may attempt to maximize family support by working with key family members. The therapist may enlist the help of various social service agencies. The supportive therapist’s role is once more similar to that of a good parent. He or she provides the help that is needed at the same time promote the client’s growth and ultimate independence.
Challenges in Supportive Therapy
It is a difficult task for the supportive therapist to maintain a right balance in the therapeutic relationship without promoting excessive dependence. Client who benefits from the supportive therapy has different level of disability so some degree of dependency is inevitable. But at the same time promoting excessive reliance on therapist may cause an adverse effect in the therapy process. Since the people who are offered supportive psychotherapy always have great difficulty in personal relationships, maintaining a therapeutic alliance with their clients is often difficult.
Supportive therapy is time consuming and is a long term therapy so this can be sometimes frustrating for the therapist especially if the therapy is with severely disabled clients. So it is probably wise to limit the number of cases with severe disability and it is better to address the counter transference issues during the supervision in order to keep the quality of the therapy.
Compared to other therapies self-disclosure has a crucial role in supportive therapy, It is a constant challenge for the therapist in deciding what, when and how much to self – disclose. So the therapist should always remember that the therapeutic relationship is different from friendship. A failure to clarify the boundary will confuse the therapist as well as the client.