546674

research-article2014
APY0010.1177/1039856214546674Australasian PsychiatryHarari

Australasian
Psychotherapy Psychiatry
Australasian Psychiatry

Supportive psychotherapy 2014, Vol 22(5) 440­–442

© The Royal Australian and
New Zealand College of Psychiatrists 2014
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DOI: 10.1177/1039856214546674
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Edwin Harari  Consultant Psychiatrist, St Vincent’s Hospital Area Mental Health Service,
Fitzroy, VIC, Australia

Abstract
Aim: The aim of this article is to describe the principles of supportive psychotherapy.
Conclusion: The author illustrates the principles of supportive psychotherapy with a case vignette.
Supportive psychotherapy is an important clinical skill for all psychiatrists.

Keywords:  supportive psychotherapy

T
he principles of supportive psychotherapy
form part of the foundations of the doctor-patient
relationship in medical practice, and of all psycho-
therapies. As a specific form of psychotherapy, it is use-
ful for two groups of patients:1
1. A previously well-functioning person psychologi-
cally destabilised by one or more life events, typically
involving loss, e.g. betrayal in a relationship, divorce,
illness in oneself or other, bereavement. Therapy aims
at restitution of the psychological status quo ante, if
that’s all the patient wants.
2. Patients with a chronic or recurrent disability, e.g.
chronic physical illness often with associated pain
and/or handicap (e.g. rheumatoid arthritis, multi-
ple sclerosis), or a chronic form of mental illness,
including personality disorder. Supportive psycho-
therapy aims to minimise deterioration and max-
imise competence within the limitations imposed
by the illness, the patient’s personality and circum-
stances, and the treating system’s resources. It may
be combined with psychoeducation or psychotropic
medication.
Supportive psychotherapy has a specific meaning
derived from psychoanalysis, which describes the thera-
pist’s support for the patient’s adaptive or more mature
personality defences. Thus, a degree of denial may
remain unchallenged in the psychotherapy of a seri-
ously ill medical patient if it enables him to persevere
with a potentially life-saving treatment. Similarly, a
patient with a borderline personality disorder who is
about to sit an exam may be allowed to rationalise that
exam stress caused him to forget his girlfriend’s birthday,
rather than exploring the possibility that such forgetting
may be an expression of his resentment. Some forms of
interpretation offered by a therapist in psychodynamic
therapy closely resemble the empathic summary of a
patient’s distress provided by a therapist in supportive
psychotherapy.2
Techniques
Contrary to a popular misconception, supportive psy-
chotherapy requires more than the doctor listening sym-
pathetically to the patient for a few minutes or expressing
concern for the patient’s plight.
Emotionally attuned listening: the doctor listens to the
patient’s story, the feelings the patient expresses and
non-verbally communicates, and the doctor’s own ‘gut’
responses. The unsaid is also important; thus, a medi-
cally ill patient who complains endlessly about treat-
ment may be avoiding the frightening question ‘am I
going to die?’
An empathic paraphrase of what the patient said and
the doctor’s understanding of the patient. Thus, to
a paranoid patient who prevaricates and asks many
questions about a proposed medication, the psychiatrist
may say:
‘From what you tell me, John, people have always let
you down, so you try to be strong and not depend on
anybody. I think you’re worried these tablets might
Corresponding author:
Dr Edwin Harari, Consultant Psychiatrist, St Vincent’s Hospital
Area Mental Health Service, 46 Nicholson St, Fitzroy, VIC,
3065, Australia.
Email: edwinharari@hotkey.net.au

440
Harari

make you weak. Maybe that’s why you don’t trust me FB (silent, sullen, eyes downcast, slumped
or the tablets?’ in his chair; he remains silent).
Consultant (gently): I wonder what might have upset
Clarification and explanation of the nature of the patient’s you? (Silence.)
difficulties and how they may be investigated and FB (mumbles): It’s the third time, this is the
helped. third time.
Reassurance and encouragement: This is not false opti- Consultant: It’s the third time you’ve had a
mism, but is reality based. So, with the aforementioned kidney transplant? (FB nods, but
patient: ‘John, I believe this medication will help calm doesn’t raise his head). And it’s too
your stress. Could you agree to try it? I’ll be here, because much for you? It’s more than you
I want to know if it’s helping and not making you weak. expected?
If you try it but don’t like it, you can tell me, and I will
FB (nods): I’ve been in three times, January
try to change it.’
2008, July 2011, and now (the
clinical impression is clearly not one
of delirium or steroid- induced agi-
Advice
tation).
The psychiatrist’s advice is based on professional knowl- Consultant: You’re right. Nowadays, kidney
edge, e.g. medication effects, the usefulness of a support transplants aren’t meant to be so
group or of taking time off work. In other matters, refer- hard. You were sick for so long,
ral to a service that deals with specific concerns is appro- then three transplants! I can
priate. imagine how each time you got
Generally, the psychiatrist avoids giving advice, but your hopes up, had the opera-
instead explores the patient’s difficulty in making a deci- tion, and then you got sick again.
sion. Typically, this reflects interpersonal problems or That could make you very wor-
the anticipated consequences of change. Reminding the ried and scared.
patient of how he went about achieving a recent success FB (nods): My wife worries a lot too; she’s all
may also challenge helplessness. by herself in W…
Consultant: So you’re in hospital, far from
Spouse and family home, worrying why the trans-
plants aren’t working; you
They are often a resource for the patient. They also have also worry about your wife,
their own distress which may also affect the patient, and you’ve just started your future
for which they may require supportive psychotherapy in together, and I guess you don’t
a couple, family or group mode. This may be combined want to show her that you’re
with specific further interventions, e.g. family psychoe- worried (he nods). That’s a lot
ducation, hospitalising the patient, or psychotherapy for for you to carry all by yourself!
a family member. (Silence.)
FB: I also wanted to go to the funeral.
Consultant: Which funeral?
Case example
FB (begins to cry): Bill, a friend.
Fred B is a 38-year-old, recently married farmer from rural
Victoria, with a history of chronic kidney disease, currently Consultant (after a Bill was important to you?
hospitalised for his third kidney transplant operation. The silence):
previous two grafts failed. The renal unit requested an urgent FB (sobbing, nods): He was like my second dad. He
psychiatric consultation following a ‘code grey’ alert when gave me my first job, and helped
Fred became agitated, verbally aggressive, threatened to pull me out with money when the
out his intravenous (i/v) and dialysis lines and to leave farm wasn’t going right.
hospital.
Consultant (gently): Could you tell us what happened
After introducing myself and other members of the psychiatry to Bill?
consultation-liaison team:
FB: He was sick for a long time, lung
Consultant: Your kidney doctors asked us to
cancer (cries).
see you because they’re worried
that you got upset. Could you tell Consultant (softly): That’s a cruel disease (silence).
us what’s happening for you? Did you know he was dying?

441

FB (nods tearfully): I saw him in January, but I didn’t
get to see him again; I rang a cou-
ple of times but he couldn’t talk;
then I got crook, and I couldn’t
go to the funeral last week.
Consultant:
So you didn’t get to say goodbye
to Bill? (nods). And his family –
do they know you’re crook?
FB (nods, talks of his close relationship
with Bill’s family).
Consultant: So you’re very sad about Bill, a
special friend, but you didn’t get
to say goodbye, and you couldn’t
help (Bill’s wife) in her sadness,
plus you worry for your wife and
your future hopes together, espe-
cially because the transplants are
going wrong. That’s a lot to handle
by yourself, Fred, but you couldn’t
actually do anything because you
were stuck in hospital!!
FB (sitting forward in the chair, mak-
ing eye contact with me for the first
time, his voice trembles but is clear):
I felt I was going to explode. I
just wanted to leave, it’s not the
staff’s fault, but I was just so … so
…(hesitates.)
Consultant: So? …
FB (pause): Angry. I know it was wrong.
Consultant: Well, you care about people, Fred,
and you try to be fair, so maybe
getting angry isn’t easy for you
(pause; Fred is looking intently at
me). And with whom could you
be angry? The staff just try to
help, you knew that, but you felt
so scared and worried; but you
couldn’t do anything about it,
you were helpless, so you blew
up with anger.
FB: That’s exactly right. (He sits back
in the chair, appears relieved and
calm.) I’m sorry, doc. (He looks
directly at me as if he is waiting to
see if I will accept his apology.)
Consultant: Fred, I think you’re the kind of
man who wants to do things, to
442
Australasian Psychiatry 22(5)
fix things, when there’s a prob-
lem; I guess that’s what a farmer
has to do to survive (he nods).
And I sense that you’re feeling a
bit guilty and ashamed for get-
ting angry and losing control, but
you just couldn’t see a solution
at the time (he nods; we are both
silent, but unlike the initial silence
it is not uncomfortable. Fred seems
calm and thoughtful, occasionally
glancing at me as if to check that
I am accepting him as he is in this
moment; I feel that we are in a state
of silent, mutual emotional syn-
chrony).
Consultant: Fred, I appreciate you telling us
about your worries and the anger;
I hope you feel I’ve understood?
(He nods.) We can talk again on
Friday. If it’s OK with you, we’ll
explain your worries to the
nurses, so you can talk to them
if those worries build up again
inside you. People find that often
happens when they’re stuck in
hospital, especially at night. My
colleague, Dr A (the psychiatry
registrar), will drop in to see you
tomorrow. And we should meet
your wife when she’s here to see
how she’s coping. Also, I think
you or your wife may have ques-
tions that your kidney doctors
could help answer, so we can talk
about that too.
FB: Thank you, doctor (he shakes my
hand warmly).
This case has been de-identified.
Disclosure
The author reports no conflict of interest. The author alone is responsible for the content and
writing of the paper.
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psychiatric practice. Edinburgh: Churchill Livingstone, 1991, 213–235.