Supportive Therapy: The Otker Therapy

by Diana McIntosh, RN, MSN, CS

Nurses kave a long history of caring for clients with

chronic mental illness. A primary treatment modal-

ity used with these clients is supportive psycho--

therapy. Often this approach is not well understood,

even by those who purport to practice it. while

supportive therapy tends not to enjoy the prestige

associated with other forms of individual psycho-

therapy, the author contends that supportive

psychotherapy can be an interesting and challenging

treatment modality for working with clients with

chronic mental illness.

s upportive psychotherapy, by definition, refers pri- marily to a form of treatment that seeks to strengthen clients’ mental functioning. The purpose is to help them cope both with their internal psychological experience and the demands of their external world. A primary goal is to sustain the current level of adjustment (Werman, 1990), although nurses often seek to improve the clients’ functioning as well.

When supportive psychotherapy is a coherent, orga- nized endeavor, it can be helpful to a large number of clients and gratifymg to the nurse as well. Even the most regressed, bizarre, or intractable clients deserve the nurse’s skillful ministrations. While compassion, empa- thy, and a nonjudgmental attitude should pervade all psychotherapeutic work, these qualities are especially important in supportive psychotherapy. The chronically mentally ill population needs well-qualified nurses skilled in supportive psychotherapy as much as they need effective case management.

Too often, supportive psychotherapy is viewed as sometlung that anyone can do - that is, anyone can sup port another person. While support means ”to hold up,” ”to sustain,” and ”to comfort,” these terms connote differ- ent t h g s to different people. Certainly to hold up is not the same as to comfort. Obviously, what constitutes sup- portive psychotherapy needs to be more clearly delineated.

Supportive Therapy

Supportive psychotherapy offers clients a symbolic form of love through contact with an empathic therapist, as well as an opportunity to vent feelings (Winston, 1986). Abigail was a 62-year-old woman who had spent 45 years in a marriage that was very unsatisfymg to her. While she did not want to get out of the marriage, she found it helpful to discuss her feehgs about it.

A supportive psychotherapist can also function to soothe clients who are angry, frightened, guilty, despair- ing, or humiliated when they are unable to do so for themselves. Children need comforting when they are hurt. If a 5-year-old boy falls and hurts his knee, a hug can do wonders to help him feel better. People never lose

26 Perspectives in Psychiatric Care Vol. 27, No. 4,1991

this need for comforting, but with maturity they becomes less dependent on others as they gain the abil- ity to soothe themselves. Some clients in supportive psychotherapy, however, have never learned to corn- fort themselves.

Terri’was a 53-year-old woman who had obtained a master‘s degree in a professional field, but was unable to practice in the field of her choice. One day as she passed by the institution in which she had been employed, she found herself becoming agitated. Unable to soothe her- self, she began yelling at passers-by because the rage she felt was so intense. She was gradually able to use sup- portive psychotherapy to help soothe her angry feelings, so that she was less inclined to yell at others when she became angry.

Who benefits from supportive psychotherapy? The client who typically benefits from supportive psy- chotherapy has a significant degree of ego impairment with deficits in perception, memory, defensive structure, reality testing, or impulse control. Supportive psy- chotherapy presumes clients are more or less severely arrested in their psychological development and require help from external sources. The client often lacks the ability to be introspective and to establish trust in inter- personal relationships. For example, the author worked with a woman who refused to share her telephone num- ber until after four months of therapy.

Goals of supportive psychotherapy. One major goal of supportive psychotherapy is to strengthen the client’s ego functioning in order to diminish deficits in impulse control. In such cases, the nurse assists clients to limit gratification and reduce the need for immediacy. Larry, a 62-year-old man with a diagnosis of schizophrenia, told his young female nurse-therapist that ”he lusted after her.” The nurse discussed the normalcy of his feel- ings, emphasizing that one could have feelings without acting on them. She then focused on the reality that sex- ual behaviors were not appropriate within the nurse- client relationship.

In supportive therapy it is important to keep the goals flexible. Initially, goals may be vaguely defined. After working with one client for several years, the therapist

decided to explore the goals this woman wanted to set. The therapist was surprised to find that he wanted to learn to knit. As this desire was met, she seemed more able to move on to goals involving leisure and activit)..

Supportive psychotherapy also attempts to modify a rigid or punitive superego, which includes providing an opportunity to ventilate painful feelings. Releasing feelings is particularly important with clients who have a chronic mental illness. Accepting their illness can be a very painful experience for them. They often believe they have done something bad or wrong to have caused their illness, or blame their families or God for their problems.

Supportive psychotherapy presumes

clients are more or less severely arrested in

their psychological development and

require help from external sources.

Therapist Involvement and Feelings

Llke insight-oriented psychotherapy, the nurse/ thera- pist encounters and tries to minimize any negative effects on the work, at times decreasing frequency of appointments or limiting time of the sessions. There is not as much ”neutrality” with supportive psychother- apy, and the nurse therapist may use some self-disclo- sure. For instance, one client inquired about the thera- pist‘s marital status when he was obviously having some preoccupation with sexual relationships. It was impor- tant at this point to speclfy when asked that the therapist was indeed married.

Working with clients who have a chronic mental ill- ness often touches the therapist at a gut level. These clients can be very lonely people. In one instance, a ther-

Perspectives in Psychiatric Care Vol. 27, No. 4,1991 27

~~~

Supportive Therapy: The Other Therapy

apist had the experience of t e h g a client that the clinic would be closed the day after Thanksgiving. The client was visibly upset and said, ”What shall 1 do? I plan on coining here every other Friday. Who will I see? This is the only place I go and the only time I take a shower.” The therapist found herself feehg very sad.

Working with clients who have a chronic mental ill- ness can be a very draining process for the nurse. There are a number of ways to deal with this situation. The nurse must keep in mind that several resources are needed to provide the adequate care and support the client requires. Nurses bring many strengths, including a holistic approach to care, but they are not and cannot be the “lone ranger.” Collaboration is essential to provide the ultimate in quality care, as well as to provide support for the nurse.

Another way to combat the draining process is to attend or to present at workshops or conferences aimed at clients with a chronic mental illness. Workshops or conferences can be rejuvenating and energize nurses to move on with this important work. Or, nurses (and other professionals) may form a group to discuss cases and articles relevant to their practice.

Patience is an important quality for the nurse working in supportive care. The nurse has to be gratified with small steps forward, keeping in mind that improvements may lead to responses from the people in the client’s environment who can further enhance his/her inner har- mony and adaptation to the external world. Change can be measured in the subtle refinement of existing person- ality strengths, and in the long, gradual move away from dependency as the motivator of relationships. If in work- ing with these clients, nurses find their consistent response is to become anxious, excessively frustrated, bored, or lonely, they should seriously evaluate continu- ing work with this population.

Therapeutic Approach

When a supportive psychotherapy approach is used, the relationship may appear superficially social in nature. However, transactions are always directed

toward certain therapeutic goals. The nurse therapist must have a firm working knowledge of the client’s psy- chodynamics so she/he does not make interpretations that weaken the client’s already failing ego defenses. While understanding the client’s resistance both on the unconscious and conscious levels, the therapist does not deal with the resistance in an active, confrontive way.

Yet nurses may find themselves in an interaction where it is necessary to set limits or to tolerate rage. The author worked with one client who came at the wrong appointment time. Enraged that the author could not see her, she threw an ashtray across the waiting room. She was told that it was okay for her to be angry about the misunderstanding, but that it was not okay for her to throw objects. Setting limits on inappropriate behavior helped her to understand the distinction between feel- ings and behaviors.

Patience is an important quality for the

nurse working in supportive care.

Flexibility. The therapist’s flexibility is essential in working with these clients. One client, who needed Prolixin D injections, would drop in sporadically when he thought it was time rather than adhere to the estab- lished schedule. The therapist suggested that the client come in around the fifth day of each month at any time during the day. He had an easy time remembering this because it was a few days after he received his disabil- ity. It proved more treatment effective to have the client drop in for the Prolixin injection, rather than schedule an appointment that he did not keep anyway. By being flexible, the nurse was able to work out a system in which the client was able to get the Prolixin on a consis- tent schedule.

Reassurance. These clients require a great deal of reassurance in a supportive approach. Cheryl is a young

28 Perspectives in Psychiatric Care Vol. 27, No. 4,1991

woman who believes that when she hears sirens, the sound means she should not be talking about the subject she is discussing. Because the outpatient in which she is seen is near several hospitals, many sirens sound during the therapeutic sessions* She needed much reas- surance that it was all right to keep talking about the

References

Werman, D. (1990). Supportive psychotherapy. HighhnR Hi~hl ig l i l s , XII(l), 17-24.

Winston, A. (1986). A review of supportive psychotherapy. Hospzfnl mid Community Psychiatry, 37(7 l), 1105-11 14.

subject she was discussing.

The nurse therapist may act as an

auxiliary ego or superego.

Boundaries. Boundary maintenance and therapeutic contracts are essential when dealing with these clients. The boundaries in supportive psychotherapy are not quite as clear when dealing with significant others as they appear to be in insight-oriented psychotherapy. Families, significant others, and staff from residential or vocational agencies are often invaluable resources. Confidentiality needs to be maintained, but it is also use- ful to be creative in obtaining and providing informa- tion. The nurse therapist also needs to be a little more flexible in boundary issues such as lateness and absences when dealing with this particular population. Some of the clients are too disorganized to keep appointments and need extensive outreach work. With others, con- tracts need to be concrete and specific. The nurse thera- pist often needs to recommend changes in the client's external life, and therefore acts as an auxiliary ego or superego. The nurse/therapist tries to keep the client in sufficient contact with reality so he/she can function.

Conclusion

The ultimate goal of supportive psychotherapy is cor- rection or rehabilitation rather than insight. The pain for these clients may go on indefinitely and nurses may play a role in their lives for a long time.

Perspectives in Psychiatric Care Vol. 27, No. 4,1991 29