Less Time To Do More…. Psychotherapy On Acute Care Units

 

Less Time To Do More….

As part of my brief series on the role of psychotherapy in psychiatry I thought I would pull this book off my bookshelves and discuss it.  It was published in 1993 and that was about the time I bought it.  At that time, I had just finished working as the Medical Director of a CMHC and consulting at a local hospital and was about 4 years into my role as an acute care psychiatrist on an inpatient unit.  I was trained in psychotherapy in residency and provided it across all of these settings as well as individual and group supervision to masters level psychotherapists.  That supervision included accepting cases referred from them for psychotherapy if they felt uncomfortable treating that person.

Managed care hit hard from my first day on the acute care unit.  Companies decided that they could easily deny care to psychiatric inpatients by using what was eventually became their dangerousness standard.  In other words, if a reviewer made an arbitrary decision that the patient was no longer dangerous, they would stop payment and the patient would be discharged.  As someone who did this work for 22 years that is a bizarre standard designed primarily save the insurance company money and they were very good at that. They were also successful in setting up a sham appeal process that could not be challenged.  The result is suboptimal care and inpatient units that are essentially revolving doors that discharge patients before they are stable.

If you think of a competency-based standard for psychotherapy – that is the ability to manage your own life and medical care, make decisions in your best interest, and problem solve and make good decisions in novel situations that was all a second priority to symptom stabilization.  If a patient was admitted because of mania and grandiose delusions – those symptoms were targeted with pharmacotherapy and once they were mostly gone – the patient needed to be discharged.  At some point in the late 1990s – public payors like Medicaid and Medicare stopped using contractors to do these utilization reviews and the process was internalized by health care organizations.  Instead of being harassed by an outside reviewer – the harassment became internal for patients covered by public insurance.

The additional context at the time was a rift in psychiatry between psychiatrists who identified as either biologically based, therapy based or eclectic meaning a combination of both (2).  This paper was written at the time I trained but even that description was an oversimplification. There were medical psychiatrists, consultation-liaison psychiatrists, neuropsychiatrists, and community psychiatrists.  They all had their models of care and their own ideas about how psychotherapy should or should not be integrated into that care.  I was fortunate to have access to a wide variety of psychotherapists and very active didactics.  But nobody really talked much about how psychotherapy fits into typical psychiatric practices. In a previous post, I listed supportive psychotherapy resources and that was an obvious skill needed across all settings.  It was occasionally demonstrated by attending physicians but most of what they seemed to do were diagnostic interviews. 

Less Time to Do More seemed to take on that problem specifically in the inpatient setting. The introductory chapter on therapeutic communities discussed a common model used to run inpatient units.  The regulatory function of the community was discussed to help patients with severe mental illnesses reintegrate following an episode of decompensation. Kohut’s self-psychology was presented as a possible model of the self-object matrix critical for early childhood development with groups and group processes taking on that role.  Groups leaders need to monitor the level of cohesion in both patient and staff groups to main their roles in assisting in self-regulation and reinforcing adaptive behavior.

Chapter 2 (3) starts to get to the heart of the matter. It discusses relevant psychodynamics at the individual patient and staff level. Inpatient treatment is ideally multidisciplinary. The team I worked with consisted of nurses, nursing assistants, social workers, and occupational therapists. Each team member plays an invaluable role in how the inpatient environment works and how it is therapeutic for patients. The psychodynamic model is the best way to make sense of it. Even then it is not an easy job. Most hospitals use siloed management with every discipline under different administrators. There is no assurance that any of the administrators know as much about how to care for patients as the inpatient staff does. There is internal politics as well as the question about what happens when there is an inevitable staff-wide crisis. Examples of those crises include threats or violence against staff members, serious allegations against staff by patients or their families, and incidents resulting in patient injury. Many of these complications can be prevented by staff awareness of the involved psychodynamics that includes transference and countertransference reactions and defenses that are typically used by people with severe psychiatric disorders and their families.

I have seen psychiatrists operate at two extremes in the acute care inpatient environment.  At one end I would call it the old hospital visit model.  The assumption is that inpatient care is basically a side hustle and most of the serious work occurs in this physician’s outpatient practice or clinic.  They appear briefly early in the morning on the inpatient unit, talk to the patients under their care briefly, do not participate in any team meetings, and may or may not talk with nursing staff.  They may depend on nurses to call them at points during the day with progress reports and decide whether to make medication changes or discharge the patient.  Before a hospitalist model in medicine – this is how many primary care physicians worked as attendings at hospitals.  

At the other end is the full time attending.  The inpatient unit is his or her primary job.  They have daily team meeting with all team members in attendance and discuss progress as well as problems. Those problems can be at the level of the individual patient, their family, the staff, the administration, the probate court, outside consultants, law enforcement, and the physical environment. Team meetings are necessarily complex and in a less time environment rapid decision making is the rule rather than the exception. The schedule of when patients are seen depends on what happens in that team meeting.  Any acute medical or psychiatric problems take priority, followed by systems problems like conflicts between staff and administrators, followed by discharges.  That all happens before noon and individual patients are seen (along with new admissions) over the rest of the day. That is the most straightforward description of this model where most days are far from routine.

A psychiatrist operating in that second environment needs certain technical skills. Above all else – they need to be aware of their personal reactions to what is going on in the inpatient environment.  How much of that reaction is reality based and how much is based in countertransference?  I heard a quote recently from Kernberg where he said the most significant work of a therapist is to contain their countertransference aggression and there is no better place to practice that than an inpatient unit. The psychiatrist operating in that environment is often a flash point for scapegoating when anything goes wrong or even not as well as expected. During my tenure it was common to see psychiatrists blamed for being assaulted by patients, for not discharging patients fast enough, for ignoring nursing staff requests, and for being too authoritarian.  In todays overmanaged health care environment any one of those complaints can trigger a major investigation by hospital committees and result in reports credentialling agencies or medical boards whether they are factual or not. Controlling countertransference aggression in such an environment can be an impossible task.

Ideally the psychiatrist is in a role with reasonable team members and can interact with them in such a way they recognize their value.  That occurs by genuine active dialogue with them discussing patient care and any problems that the staff member might be having. This may seem obvious but it was not until my first few years as an inpatient psychiatrist that I realized the only reason my patients were in the hospital was that they needed nursing care.  I could do my 30–60-minute visits anywhere. The nursing staff was with them 24/7 and for clear reasons.  Other disciplines also need support form psychiatry.   Inpatient social work is a clear example.  The social workers I had the privilege of working with were all excellent and found themselves doing the impossible job of discharge planning.  They were calling 20-30 places a day for a single patients trying to get them out of the hospital (we rarely discharged anyone to the street).  That is a high stress situation especially when you have a supervisor asking you why you have not seen enough of the other patients.

All of these scenarios require a psychiatrist who can intervene supportively (education, encouragement, problem solving) and existentially (empathic listening and reflection) with fellow staff members.  That does not mean they are doing supportive psychotherapy with their colleagues.  It does mean that the genuine and human interactions they have with their valued coworkers may translate well into the therapy they are able to do to assist patients.  It may also lead to valuable insights like the one I had about the nursing staff. 

Additional chapters in this book provide good information on interacting with outpatient therapists and the importance of recognizing potentially disruptive defense mechanisms like projection, projective identification and splitting and how they can be contained on inpatient units. Containing countertransference aggression was emphasized especially because it can be magnified more in an inpatient setting where there are more possible recipients.     

The authors were generally confident about providing inpatient psychotherapy to a patients with a diverse number of conditions.  Some of the time frames discussed approximated 2 weeks and these days that is about a week longer than many these days. Some variables affecting length of stay (LOS) were not discussed.  The most important one of these is involvement in civil commitment and how that is handled. I looked at the issue on my unit and it added another 21 days and even longer after the State of Minnesota passed a law allowing county sheriffs to send mentally ill inmates directly to state hospitals on a priority basis. Like all inpatient factors it was a mixed blessing – more time for all therapies and recovery but the wrath of administrators blaming staff for not using enough medication fast enough, doing too many civil commitments, or not discharging unstable patients.

My approach in the inpatient setting was to have daily team meetings, engage my team in productive patient focused discussions, and see all my patients for at least 30 minutes a day.  I would also see family members at their request when they came in to visit or scheduled family meetings with or without my social work staff and at times nursing staff of they had available time.  I was very focused on the phenomenological-empathic approach to interviewing people with severe problems. I generally felt that patients realized that I was very interested in talking to them about more than symptoms.  Just that aspect had significant effects on people who were angry, non-disclosing, paranoid and accusatory, and used projection and splitting defenses. I was able to establish long term relationships with many people who were considered refractory to treatment and they were able to make progress.

Part of those discussions involved a detailed discussion of delusional thought content and how it was affecting their life. I commonly asked for their initial experience and the very first time they had those thoughts.  We would reconstruct that incident and discuss what happened as a place to begin.  From there we would discuss how these thoughts affected their relationships and ability to manage their lives.  I found that asking them about their theory of what happened or was happening to them was a useful question. Once their theory was discussed we could discuss whether they were aware of other possible theories to explain what happened.  This is a much better approach than getting into an argument of who believes what.  “Well, I understand you believe that!” is a judgmental rather than an empathic statement that simply states that you are not interested in what the patient has to say. 

Inpatient psychotherapy is also a place where competency can not only be emphasized but it may be critical for survival.  Exploring why a patient believes that they do not have diabetes or a fatal illness and trying to help them with a working solution is one example.  Working with them on how to avoid confrontations with the police is another. I have worked with many manic patients who found themselves in life threatening situations when they overestimated their physical abilities due to mania. And there are the more frequent discussions of how to avoid hospitalizations, how to manage severe psychiatric illnesses including suicidal thoughts and inability to function at times.

The thousands of discussions I have had with these folks over the years led me to the conclusion that supportive psychotherapy is the language of psychiatry.  On the inpatient unit it operates at multiple levels in a very high stress environment.  In the next few posts, I will look at more specific interventions.

The main theme I am hoping to stress in these posts is that no matter what you are going as a psychiatrist – a psychotherapeutic intervention should be part of it. It reminds me of a thought experiment one of my brightest teachers presented to ma as we were talking after clinic one day:

“OK George - suppose you are out there as a psychiatrist for a few years and you are at a party.  A woman comes over to you at that party that you don’t know and starts to make small talk. Are you thinking like a psychiatrist or not?”

The tenor of these posts should suggest the answer…..

 

George Dawson, MD, DFAPA

 

 

References:

1:  Leibenluft E, Tasman A, Green SA (eds).  Less Time To Do More: Psychotherapy on the Short-Term Inpatient Unit.  Washington, DC. 1993.

This is a 1993 publication so I am not recommending it at this point. It is a good outline of necessary psychotherapeutic concepts but is not long on specifics apart from some vignettes.

2:  McHugh PR. William Osler and the new psychiatry. Ann Intern Med. 1987 Dec;107(6):914-8. doi: 10.7326/0003-4819-107-6-914. PMID: 3318611.

3:  Silver PA, Goldberg RL.  Integrating Somatic and Psychological Treatment in Inpatient Settigs. in:  Leibenluft E, Tasman A, Green SA (eds).  Less Time To Do More: Psychotherapy on the Short-Term Inpatient Unit.  Washington, DC. pp: 23-38.

Compartmentalization In Psychotherapy

 

I had this thought after my post about supportive psychotherapy in psychiatry.  In the experience of most psychiatrists, it plays a major role.  The related questions are – why isn’t that role acknowledged and why are psychiatrists even reluctant to use the term.  I had the thought that it is due to compartmentalization and before I research that concept to see if anything has been written about it - I thought I would write down my observations.  

The first thing that comes to mind is the idea that psychotherapy needs to be provided according to a specific formal or informal protocol and a prescribed number of sessions. Psychoanalysis is the obvious prototype of a specific method that can include the number of sessions and approximate duration of therapy.  Over the years the method has been adapted to shorter courses including crisis intervention and both transference- based and non-transference-based psychotherapies.  Psychodynamic therapy has been manualized (Klerman, Strupp, Luborsky) and adapted to both crisis intervention (Viederman) and short-term settings (Sifenos, Gustafson).  Hybrid versions such as psychodynamic and cognitive behavioral therapy (Garret) and existential-psychodynamic therapies (Yalom) have been developed. Complex developments like this probably have many people questioning where to draw the lines.

The second issue is how all these developments fit into psychiatric practice.  You can be a psychoanalyst and maintain well defined courses of therapy and a consistent technique. Some psychoanalysts practice part time and have a separate psychiatric practice.

A third issue is how supportive psychotherapy gets implemented in more common types of practice.  The most common expectation of employed psychiatrists these days is seeing 3 or 4 new patients a day and another 8-10 follow up patients.  Most of the practice includes patients with severe psychiatric disorders that require medical treatment and ongoing assessment and treatment of both medical and psychiatric disorders.

An exciting idea is the ability to provide supportive psychotherapy to all people seen in those settings.  A common stereotype promoted in the press is the idea that people are seen for medications only.  The usual reasons given is that this is the best way for psychiatrists to make money and/or it is a sign that pharmaceutical companies have manipulated psychiatrists into providing care this way.  I have illustrated many times on this blog that all those ideas are incorrect.  Today I want to approach the issue form the perspective of psychotherapy.

It is very difficult to maintain any kind of useful relationship with a patient solely discussing medications. That is true for any physician but most importantly psychiatrists. What else happens in those appointments? Non medication related situations are discussed.  Life is inevitable and people who are stabilized on medications still encounter stressors and crises just like everyone else.  The main difference is that most of the people seeing psychiatrists have major psychiatric disorders that can be destabilized by stress.  They also have first-hand experience with medications that have been useful in the course of their illness.  In those situations, there needs to be a detailed discussion of whether the crisis represents an exacerbation of the primary disorder or something else. That appointment will typically require more than an answer to that question. The patient wants to feel understood by a person who knows them well, wants to leave the appointment feeling better then when they arrived, and wants some ideas about what can be done to alleviate their suffering. A prescription may be added or changed but it is not the primary intervention in that scenario – supportive psychotherapy is. 

Even in scenarios where consultations are done in high acuity settings – there needs to be enough flexibility to recognize the true nature of the problem and intervene psychotherapeutically.  The following vignette illustrates that point:

The patient is a 70-yr old woman who was acutely admitted to the CCU with chest pain to rule out a myocardial infarction. On day 2, the Cardiologist caring for her sends a psychiatry consult because he is concerned that she is depressed and a possible suicide risk.  The psychiatric consultant sees her and observes a depressed appearing women who seems healthy and vigorous.  The consultant notes she recently retired as the CEO of a large company and is having some difficulty adapting to that transition.  She had anticipated travelling in retirement but her husband has a chronic illness and she is the primary caregiver.  The discussion focused on the role transition and existential issues associated with retirement.  She agreed to follow up discussions in the outpatient clinic.  Following the consultation – the consultant met with the Cardiologist and explained the formulation, that antidepressants did not seem to be indicated, and that a suicide risk assessment had been done and that the risk was low and that inpatient treatment was not indicated. 

In the example above this was a typical extensive consultation done on medical-surgical patients.  Psychiatric consultation is critical in these situations because it affects the discharge process of beds with rapid turnover and keeping a patient there longer than necessary can be a major problem. Despite the intensity of that information gathering the consultant can do a supportive psychotherapeutic intervention that the patient was interested in pursuing. It requires a consultant who can quickly identify the relevant theme for psychotherapeutic intervention. I would see this as a problem in pattern recognition that does not seem to be discussed very much in the psychotherapeutic literature.  Most of the discussion of patterns is focused on object relations and the recurrent themes in relationships, although Klerman, et al discuss role transitions as a potential cause of depression. The existentialist may say that meaningfulness may be a better conceptualization.

This is one of many examples of how psychotherapy does not need to be compartmentalized as a separate intervention and can be added into the assessment or any scheduled appointment.  Instead of thinking of psychotherapy as a 40-50 minute block of time once a week – can it be 10-20 minutes weekly in addition to everything else occurring in that appointment? 

People tend to think of psychiatric appointments these days as “med checks”.  This was modified slightly a few years ago when psychiatrists were allowed to use standard E&M (Evaluation and Management) billing codes like all medical and surgical specialists.  There is a complexity dimension and even a psychotherapy dimension.  The main problem with all these billing codes is that they are not reality. They need to be completed to get reimbursement and they need to be completed in a rigid stereotyped way – but they cannot be counted on to reflect the reality of the session. They are constructed for business purposes and not clinical purposes and that is evident if you read a handful of the notes.  You are likely to see a template of required bullet points that are generally headings of evaluations or symptom lists.  They contain limited useful information and nothing about the real exchange between the patient and the psychiatrist.  They say nothing about the shared experience in the room or the quality of that relationship. 

That also suggests a lesser-known form of supportive psychotherapy and that is existential therapy.  In psychiatry, existential psychotherapy leads to association to work by Victor Frankl, Ludwig Binswanger, Leston Havens, and Irwin Yalom.  Although there are some academic psychology departments that specialize in it, most of the psychiatrists and psychologists I know who were self-identified were trained as psychodynamic therapists or psychoanalysts first. Yalom had stated that is probably the best training for existential therapy and most available. For this post, an interesting adaptation of existential therapy is the application to brief visits suggested by Ghaemi and co-authors.      

As you study existential psychotherapy – arriving at a coherent current approach and strategy may seem like an impossible task. Some of the early work by Minkowski and that work reviewed by Havens includes some techniques that I have encountered in other therapies – like paradoxical intention. Binswanger’s description of approaching a patient with mania is probably the most accessible.  The best distillation of the process is probably Ghaemi’s 2018 description of existential psychopharmacotherapy.  He suggests an open-ended interview style – even in patients being seen for brief medication-based visits. The goal is to encourage spontaneity and expression.  Allow the patient to provide the narrative that they think is the most important.  Questions relevant to the medication can be asked later in the interview – but the more open format allows the patient to describe their current problems, symptoms, and adverse effects in their own terms rather than the rigid descriptors of the DSM or associated checklists. Most importantly the interview is focused on phenomenology or the personal internal state of that patient rather than group averaging that may not apply. In the context of empathic understanding by the psychiatrist – the patient feels understood and the therapeutic alliance is enhanced. The alliance is necessary for discussions of the treatment plan, its modification, and informed consent. This is a common form of psychiatric practice, although most practitioners would be hard pressed to discuss it as an existential approach. Many do describe it as supportive or humanistic. Consistent with the compartmentalization theme of this post – most psychiatrists do not think of it as therapy even though it is a critical aspect of psychiatric practice.

Psychodynamic therapies also have several short-term approaches and like existential psychopharmacology.  Some of those authors have described approaches that can be used in crisis intervention with or without medication and during brief visits with a medication focus.  Gustafson discusses specific implementations as common dynamics in psychiatry.  He discusses a trial intervention that can be done in less than 10 minutes.  It is primarily a clarification that makes sense of the current anxiety or depressive state as a natural consequence of what they may be trying to avoid and provides a theory for the mood state.  I have seen similar interventions used in cognitive behavioral therapy.

I hope that I have been clear about the issue of compartmentalization in psychotherapy.  It can occur at the macro level with the silos of major therapies (some 200 by one estimate). Thise silos are often reinforced by practitioners engaged in debates about the design of trials, efficacy, and who is the most “evidence-based”.  Even after those technical and political issues are brushed aside, practitioners are faced with rigid ideas about how psychotherapy needs to be provided. The reality is that every encounter with a psychiatrist should be conducted as though it is psychotherapeutic and there are plenty of options to consider.  The good news is that I am sure a lot of it is occurring already – but because of the classification problem – it is not being counted.  

 

George Dawson, MD, DFAPA

Supplementary 1:  I omitted one of the main factors responsible for compartmentalized psychotherapy to improve the readability of the post and that is managed care constraints.  Managed care is an insidious force that affects all aspects of psychiatric and mental health care.  In psychotherapy when I worked in a CMHC - our therapists had to complete pages of documentation just to provide indicated psychotherapy to people with chronic mental illnesses.  Later when I worked for a managed care company - they had reviewers that approved psychotherapy on a session by session basis.  In some cases they would decide that 3 sessions of psychotherapy were enough and stop payments at that point.  I have also been told that they do not cover psychotherapy provided by a psychiatrist and that I needed to refer to the patient to a counselor.  Even in the ideal world where a course of brief therapy is recommended for a duration of 8-12 session (from the research) it was rare to see a patient receive that many sessions.  Billing, coding, and utilization review are all impediments to psychotherapy. 

References:

Frankl VE. Logotherapy and existential analysis—a review. American Journal of Psychotherapy. 1966 Apr;20(2):252-60.

Binswanger L.  On the manic mode of being-in-the-world.  In:  Strauss E. Phenomenology Pure and Applied.  Pittsburgh.  Duquesne University Press; 1964.

Yalom ID.  Existential Psychotherapy. New York: Basic Books; 1980.

Längle A. From Viktor Frankl’s logotherapy to existential analytic psychotherapy. European psychotherapy. 2015 Feb 18;12:67-83.

Havens LL. The existential use of the self. Am J Psychiatry. 1974 Jan;131(1):1-10. doi: 10.1176/ajp.131.1.1. PMID: 4808428.

Havens LL. The development of existential psychiatry (Karl Jaspers, E. Minkowski, and Otto Binswanger). J Nerv Ment Dis. 1972 May;154(5):309-31. doi: 10.1097/00005053-197205000-00001. PMID: 4554757.

Ghaemi SN. Rediscovering existential psychotherapy: the contribution of Ludwig Binswanger. Am J Psychother. 2001;55(1):51-64. doi: 10.1176/appi.psychotherapy.2001.55.1.51. PMID: 11291191.

Ghaemi SN. Feeling and time: the phenomenology of mood disorders, depressive realism, and existential psychotherapy. Schizophr Bull. 2007 Jan;33(1):122-30. doi: 10.1093/schbul/sbl061. Epub 2006 Nov 22. PMID: 17122410; PMCID: PMC2632297.

Ghaemi SN, Glick ID, Ellison JM. A Commentary on Existential Psychopharmacologic Clinical Practice: Advocating a Humanistic Approach to the "Med Check". J Clin Psychiatry. 2018 Apr 24;79(4):18ac12177. doi: 10.4088/JCP.18ac12177. PMID: 29701934.

Gustafson JP.  Reading the ability of the patient to change his or her life.  Psychiatric Times.  February 2007, Vol. XXIV, No. 2    https://www.psychiatrictimes.com/view/reading-ability-patient-change-his-or-her-life

Photo Credit:

Many thanks to Eduardo Colon, MD for allowing me to use his photos. 

Supportive Psychotherapy - The Clinical Language of Psychiatry

 

 

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. 3^rd ed. London: Saunders; 1995.

3:  Oyebode F.  Sims’ Symptoms in the Mind: Textbook of Descriptive Psychopathology. 6^th 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.  2^nd ed. New York: Basic Books; 1969.

10:  Battaglia J.  Doing supportive psychotherapy.  Washington, DC: American Psychiatric Press: 2020.

11:  Novalis PN, Rojcewicz SJ, Peele R.  Clinical Manual of Supportive Psychotherapy.  Washington, DC: American Psychiatric Press; 1993.

12:  Novalis PN, Singer V, Peele R.  Clinical Manual of Supportive Psychotherapy.  2^nd 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.