An interesting topic came up a few days ago – how do you
decide if what the patient is describing is just reality-based anxiety as
opposed to a more global psychodynamic issue?
It sounds like a basic problem but it is not. A common example is the
scenario where one person in a couple (married or not) decides to leave the
other precipitating an emotional crisis in the remaining person. In daily living there are a large array of
acute and subacute stressors related to losses, conflicts, accidents,
illnesses, moral injury, and other life transitions. In psychiatric practice they occur across
settings including emergency departments, acute care units, and even in
patients who are considered stable and being seen on a long-term basis. These situations are generally context
dependent and require psychotherapy skills as the primary intervention.
In all the debate about the role of psychotherapy in
psychiatry over the years – the obvious problem of emotional crisis gets left
out. It is as if psychiatrists
are calmly assessing people for medical treatment – like an internist would
assess somebody for hypertension and then advise them about the treatment. The reality of psychiatry is that people are
in a highly emotional and at times agitated state. It is impossible to proceed with any kind of
evaluation unless you can help them calm down, organize their thoughts, see the
psychiatrist as a relative ally, and proceed with the interview. There is no guarantee that will happen, but
being trained in crisis situations and evaluations greatly increases the
likelihood that a positive working relationship with the distressed person can
be developed and used to help them.
How do I know that to be true? I have been in that situation thousands of
times and rarely found myself in a non-productive interview. I have
successfully done crisis intervention with psychotherapy alone and no medication
prescriptions. No prescriptions is not a definitive marker for success – but I
have seen the other end of the spectrum.
People in acute distress from being fired, separated from their spouse,
or acute bereavement who were suddenly started on antidepressants or
anxiolytics after a few days of anxiety or depression and a very brief
assessment. I have stopped many of those medications by the time the patient was
done seeing me.
What exactly is a crisis and how does talking help? I go back to the very first book I read on
supportive psychotherapy (1). Werman defines
a crisis as an acute deficiency of mental functions that allow people to
tolerate the demands of the external world and the inner psychological
world. More specifically:
“The acute deficiency which we call a crisis, occurs when a
patient whose life may previously have been in a state of reasonable
equilibrium has more or less suddenly become deeply disturbed by a stressful
event that may be real, symbolic, or fantasized, and that
has precipitated a condition of psychological insufficiency.” (p. 5).
It would follow that the stressful event could be a
combination of reality, symbolism, and fantasy.
Most of these crises resolve without psychiatric or mental
health intervention with varying durations.
They also happen commonly across all aspects of psychiatric practice
including inadequately resolved crises that can present years later after
transitioning to a more permanent psychiatric disorder. A common example is sudden unemployment. That
crisis is most commonly resolved by getting support during the period of
unemployment and transitioning back into the work force. But some people have a
difficult time with that transition and develop mood or anxiety disorders. In some cases, it can result in permanent
disability.
The correct approach when seeing someone in a crisis is
knowing what can be done to restore their psychological equilibrium. There are suggestions about how to approach
that problem in supportive psychotherapy from various schools. From a technical perspective, supportive
psychotherapy originating from psychodynamic schools of thought requires an
understanding of those dynamics from the patient but in the short time horizon
of the crisis does not usually involve interpretation of the underlying
unconscious conflicts. It also tends to
focus on affect rather than cognition or behavior. It may involve reinforcing defenses or suggesting
defenses and generally clarifying some restricted thinking that is an artifact
of the effect of the crisis. People in
crisis often exhibit catastrophic or similar forms of restricted thinking that
can be reviewed and discussed during an empathy-based interview. Alternate interpretations can be discussed
with the patient and the effect on their affect noted. Listening and empathic responses are very
useful interventions in decreasing patient distress.
To perform this kind of intervention it assumes certain
requirements on the part of the therapist.
An empathic interview style is required.
In medical schools - empathy and an associated non-directive interview
style is typically taught in the second year before the clinical years
start. Since this is a psychiatry blog,
I want to add a psychiatric definition of empathy and that is:
“Empathy is achieved by precise, insightful, persistent, and
knowledgeable questioning until the doctor is able to give an account of the
patients subjective experience that the patient recognizes as his own.” (2)
Subsequent editions (3) are more specific in how this is
achieved but also describe the concept as controversial. This is how I would understand it. The basic problem is communication between
two people with unique but also similar conscious states. The person in crisis understands at some
level that the psychiatrist can understand them based on that shared humanity.
They want to say what happened and be understood. That requires the
psychiatrist to be genuinely interested in the mental life of the other person
and to avoid any potential obstructions to the flow of information. Therapeutic
neutrality is a goal as well as the psychiatrist being aware of any personality
characteristics that may get in the way – like impatience or getting bored or
annoyed. The psychiatrist experiences
some of the detailed descriptions of what happened to the patient and can
resonate with them based on life experience.
Based on that recreation of patient experience the psychiatrist can
comment on the associated affect and confirm with the patient that it is their
subjective experience. The controversy
about this approach involves the fact that not every experience the patient has
(eg. psychosis) has been experienced by the psychiatrist – there are therefore
limits to this method.
The concept of phenomenology is also relevant here. It
refers to an examination of the patient’s conscious processes – specifically
the events that brought them in for consultation- and the associated
behavior. It is a detailed description
without any attention paid to theories about how the state occurred or evolved. It is based on an empathic understating of
the patient’s internal state. Both
concepts – empathy and phenomenology are tools for developing an understanding
of the patient and communicating that understanding to them.
In a crisis, there is a time constraint that is also a
factor. To use empathic and phenomenological methods typically requires a
significant amount of time for the initial descriptions of the patient’s mental
state and additional clarifications. In many settings there is an emphasis on a
diagnosis and more specifically – a diagnosis as an explanation rather than an
initial understanding of the problem. A
supportive psychotherapy approach will be focused on the former rather than the
latter.
An additional part of any crisis assessment includes an
evaluation for safety and whether the patient is at risk for self-injury,
injury to others, or not being able to provide basic self-care. There are many
considerations for the safety assessment that cannot be covered in this
post. For this post - assume there are
no significant safety concerns following that assessment.
There are a wide variety of interventions available. A few are listed in the box below referenced
by some of the authors I have listed.
An important concept in supportive psychotherapy is that many of the current manualized or structured therapy approaches were taught as supportive psychotherapy before they became what appear to be separate schools of thought. For example, when I first read about interpersonal therapy for depression (4) and cognitive behavioral therapy for depression and anxiety (5) – I realized that I had been using these approaches in what I called supportive psychotherapy. During the period I was trained my psychotherapy supervisors had varied theoretical backgrounds and had Rogerian, psychoanalytical, psychodynamic, existential, and behavioral orientations. They worked in practice environments where people presented with severe problems. Some had experience in shifting from one paradigm to another based on whether the patient was making progress or tolerating the current interventions. The best example in that case is this diagram from Kroll (6) on treating patient with borderline personality disorder.
|
Modalities of Psychotherapy |
||
|
|
Supportive |
Exploratory |
|
Content |
WINDOW A Openly supportive Behavioral-didactic focus Problem-solving Competency based |
WINDOW B Explores patterns in life-events |
|
Process |
WINDOW C Identifies process occurring in
therapy Provides support for changing the
process toward competency |
WINDOW D Explores process occurring in
therapy Explores relationship of therapy to
life patterns |
Kroll begins his discussion of the diagram by this
disclaimer that anticipates philosophical criticisms of psychiatry for the next
40 years: “The reader and the author must keep in mind that a schematic
model is an artificial device having heuristic value and ought not to be
mistaken as transmitted truth or a piece of reality. It is a way of organizing
our observations and thoughts; too literal an adherence to any schema,
especially a simplified one, will result in greater problems than benefits.”
(p. 103).
He then goes on to illustrate by example how a young patient
with parental conflict could be addressed in any of the 4 windows in his
table. He points out that are therapies
have elements of supportive and exploratory therapy and that in a typical
therapy session the therapist can move between windows based on their
experience and judgment about timing. I
plan to illustrate this with an example from Viederman and his original
psychodynamic life narrative in a subsequent post. I also plan to illustrate additional
supportive therapies based on the common factors model in psychotherapy and
behavioral activation as a supportive psychotherapy for depression.
It is not very common knowledge that supportive psychotherapy
has historical roots in psychiatry and is both evidence and empirically based. The first physician to use the term
psychiatry was Johann Reil (1759-1813) a German physician described as a
physiologist, anatomist, and psychiatrist. In 1803 he wrote Rhapsodien uber die
Anwendung der psychischen Kurmethode auf Geisteszerrüttungen ('Rhapsodies about
applying the psychological method of treatment to mental breakdowns') that included
a method of supportive psychotherapy (11,12). Modern techniques of supportive
psychotherapy have be used in clinical trials in some cases as placebo but in
many of these trials the performance of supportive psychotherapy is equal to or
superior to the psychotherapy intervention being studied (13).
Supportive psychotherapy has come a long way since the time I learned it nearly 40 years ago. Like most things in psychiatry the issue of psychotherapy is always highly politicized due to several factors. When I learned it – polarization between the psychiatrists who considered themselves therapists as opposed to biological psychiatrists was at an all time high. I can still recall walking into the room with those biological psychiatrists when I had to staff patients with them and listening to what they were saying to the patient. I would end up thinking: “Wait a minute this biological psychiatrist is doing supportive psychotherapy!” That is an oversimplification – I was taught by some of the best psychiatrists in the country if not the world and most of them were clear that both psychotherapy and biomedical psychiatry were skills that all psychiatrists needed to have. Supportive psychotherapy is a language for communicating with patients and it alway has been.
George Dawson, MD, DFAPA
References:
1: Werman DS. The Practice of Supportive
Psychotherapy. New York: Brunner/Mazel
Publishers; 1984.
2: Sims A. Symptoms in the Mind: An Introduction to
Descriptive Psychopathology. 3rd ed. London: Saunders; 1995.
3: Oyebode F. Sims’ Symptoms in the Mind: Textbook of
Descriptive Psychopathology. 6th ed. London: Elsevier; 2018.
4: Klerman GL,
Weissman MM, Rounsaville BJ, Chevron ES.
The Interpersonal Psychotherapy of Depression. New York; Basic Books; 1984.
5: Beck AT, Rush AJ,
Shaw BF, Emery G. Cognitive Therapy of
Depression. New York; Guilford Press;
1979.
6: Kroll J. The Challenge of the Borderline Patient. New
York; WW Norton and Company. 1988: p. 104.
7: Viederman M. The
psychodynamic life narrative: a psychotherapeutic intervention useful in crisis
situations. Psychiatry. 1983 Aug;46(3):236-46. PMID: 6622599.
8: Viederman M. Clarification: A Powerful Therapeutic
Strategy in Psychodynamic Psychotherapy. Psychodynamic Psychiatry. 2025; 53(2), 172–183.
9: Dewald PA. Psychotherapy: A Dynamic Approach. 2nd ed. New York: Basic Books;
1969.
10: Battaglia J. Doing supportive psychotherapy. Washington, DC: American Psychiatric Press:
2020.
12: Novalis PN, Singer
V, Peele R. Clinical Manual of
Supportive Psychotherapy. 2nd
ed. Washington, DC: American Psychiatric
Press; 2020.
13: Markowitz JC.
Supportive Evidence: Brief Supportive Psychotherapy as Active Control and
Clinical Intervention. Am J Psychother. 2022 Sep 1;75(3):122-128. doi:
10.1176/appi.psychotherapy.2021.20210041. Epub 2022 Mar 2. PMID: 35232221.
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