A New Formulation of Supportive Psychodynamic Psychotherapy


CHAPTER 8




A New Formulation of Supportive Psychodynamic Psychotherapy


 


 


What follows is an effort to make use of the new knowledge and experiences that we have acquired at the Personality Disorders Institute of Weill Cornell Medical College regarding the application of transference-focused psychotherapy (TFP) to the treatment of severe personality disorders. Two major concerns have moved us to reexamine the concept and techniques of supportive psychotherapy based on psychodynamic principles.


First, would it be possible to develop an updated method of supportive psychodynamic treatment for cases that have traditionally been treated in a supportive modality? These include cases of such minor degree of severity that brief psychodynamic psychotherapies are sufficient to treat effectively. At the other end of the spectrum are more severe cases that have not responded to, are contraindicated for, or otherwise do not present sufficient conditions for carrying out TFP or other intensive psychodynamic psychotherapeutic treatments. These latter cases include a significant number of severe personality disorders that have not responded to a wide spectrum of psychodynamic and cognitive-behavioral treatments carried out with appropriate expertise over a sufficiently extended period of time (Rockland 1989).


Our second concern is a very practical one: the societal and financial pressures for reducing the frequency of treatment to one session per week, which presents an impediment for carrying out TFP, which requires a minimum of two individual sessions per week. In fact, therapists whom we have trained to carry out TFP with patients with severe personality disorders have attempted, under the pressure of socially determined constraints, to maintain this treatment on a once-per-week basis (“TFP light”). Whereas some patients seem to have responded to once-per-week TFP, many other patients ended up in long-term treatments without adequate therapeutic response. This calls for further empirical research to determine patient–therapist characteristics that might predict successful once-per-week TFP. In practice, under the circumstances referred to above, supportive psychotherapeutic techniques became necessary to deal with transference developments that could not be explored from a technically neutral viewpoint. Given the urgency of multiple problems reflecting these patients’ poor social functioning and requiring rapid interventions under the conditions of a once-per-week treatment situation, interfering transference resistances could not be interpretively resolved.


Our encounter with these obstacles has motivated us to reexamine the possibility of developing a supportive psychotherapeutic approach that could be carried out on a once-per-week basis, making use of our experiences in treating severe personality disorders with TFP while maintaining an internal coherence of the treatment that would provide an adequate frame for the therapist’s interventions within a clear theory of technique.


Traditional Definition and Changes in Psychodynamically Based Supportive Psychotherapy


The model of traditional supportive psychotherapy based on psychoanalytic theory and psychodynamic techniques centers on the effort to help the patient achieve a better equilibrium between defenses and impulses, strengthening ego functions by reinforcing adaptively useful defensive operations and making use of positive transference developments in fostering the patient’s identification with the therapist’s healthier ego functions (Gill 1954). This conceptualization, developed in the 1950s and 1960s in the United States, expanded further in later decades under the influence of the findings of the Menninger Foundation’s Psychotherapy Research Project (Kernberg et al. 1972). It eventually led to the manualized supportive psychotherapy for borderline conditions carried out under the leadership of Lawrence Rockland and Ann Applebaum at our Personality Disorders Institute, and was explored in a randomized controlled treatment that showed both positive effects and limitations of that approach (Kernberg et al. 2008; Rockland 1989).


The following influences from our ongoing development of TFP seemed important in terms of a contemporary review of supportive psychotherapy. First, we noted the contributions from contemporary psychoanalytic object relations theory. It became evident that primitive defensive operations based on splitting mechanisms, including projective identification, denial, omnipotent control, devaluation, primitive idealizations, and severe splitting of self and object representations, had significantly weakening effects on ego functioning. The concept of “reinforcing adaptive defenses” became less relevant than the need to reduce the dominance of these primitive defensive operations. The awareness of these defenses replaced the older concept of the assumed “frailty” of the patient’s ego. The apparent frailty of the patient’s self experience and self-concept was a consequence of these primitive defensive operations, in the same way as the patient’s distortions of his or her experiences in the relations with significant others. A supportive psychotherapeutic approach would have to focus on these negative effects of the patient’s habitual defensive operations.


Second, the use of modified psychoanalytic techniques in TFP opened the possibility of using some aspects of these technical modifications in combination with other, supportive techniques as part of an essentially supportive approach that would reflect our experience with the severe life problems and crises of severe personality disorders.


Third, we had become acutely aware how crucial was an ongoing monitoring of the patient’s functioning in the major areas of daily living—that is, in work and profession, in love and sex, in social life and creativity. We had to assess the urgency of the patient’s life problems at any time, along with the corresponding need for shifts in the priority of the therapeutic interventions.


Last, our experience with constant attention to transference developments permitted us to diagnose more appropriately the activation of manifest (in contrast to latent) negative transferences that, in a supportive approach, necessarily would have to be dealt with to maintain a minimal therapeutic alliance in carrying out the tasks as agreed on in the patient–therapist relationship.



A Newly Defined Strategy of Treatment


The strategy of supportive psychotherapy we developed involves an effort to improve the patient’s overall functioning without attempting to resolve identity diffusion (Kernberg 1999). We focused on helping patients to become aware of the many ways in which their dysfunctional responses to emotional tensions and triggers perpetuate their difficulties, and how alternative ways of dealing with these tensions may improve their functioning and well-being. The main objectives of this supportive treatment refer to the patient’s better functioning in the major areas of work and profession, love and sex, social life, and creativity, but with a clear recognition that improvements in love and sex may have the greatest limitations without the benefit of a more traditional psychoanalytic approach. Supportive psychotherapy may not be able to resolve the profound limitations in these patients’ capacity to love and to integrate tenderness and sexual desire. This limitation notwithstanding, modifications of behavior that can be achieved in the areas of work and profession, social life, and creativity should provide a broad spectrum for areas of improvement.


Practically, therefore, the strategy of treatment would depend on highly individualized goals derived from a full assessment of the patient’s present difficulties and the evaluation of his or her potential for resolving them to a lesser or greater extent. This relates to an immediate tactical aspect of the treatment at its very start, namely, the patient’s potential in the therapist’s fantasy. In other words, what does the therapist construct in his or her fantasy about the possibilities that this particular patient has to improving his or her limitations? What would the patient be able to do if he or she were not tied down by his characterological and symptomatic restrictions? A related countertransference issue involves the question: What would the therapist do if he or she were in the patient’s body, exactly in his or her present position, but with the therapist’s capacity to assess the situation and the knowledge of what he or she could do to improve it? These questions illustrate the importance of the initial countertransference reaction in terms of sympathy and antipathy, hope and skepticism, interest, or pity and despair that the patient may evoke for the therapist before more subtle aspects of transference developments take over—in short, a realistic establishment of treatment goals in the mind of the therapist, which then can be discussed and negotiated with the patient. These agreed-on priorities are a modification of TFP in that the therapeutic goals from the outset are more modest than the aim of resolving identity diffusion and structural change.



Major Treatment Techniques in the Application of Supportive Psychodynamic Psychotherapy


A MODIFIED INTERPRETIVE APPROACH


Preliminary techniques of interpretation—that is, clarification and confrontation—are freely used to help the patient become fully aware of the meaning of his or her communications and interactions in the sessions, signaling both appropriate and inappropriate and clear versus problematic or confused aspects of the patient’s narrative in an effort to clarify both the immediate reality of the therapeutic interaction and the reality of the interactions that the patient establishes in his or her environment. An important reminder to the therapist doing this work is, if you don’t understand something, ask until you do. At this point, supportive psychodynamic psychotherapy (SPP) is modified from TFP in that the therapist would stop short of interpreting the unconscious meanings of the interactions and their relation to the patient’s unconscious past. Interpretation at this level would be limited to one aspect of the transference, as follows.


TRANSFERENCE ANALYSIS


In contrast to standard TFP, transference analysis is not carried out systematically, and positive transference is used to sustain and reinforce the patient’s capacity to respond positively to the supportive techniques that will be dominant in the therapist’s repertoire. Used only in the case of manifest negative transference, full clarification and confrontation of it would be followed by an effort to explore its origin, inasmuch as the patient is able to do at a preconscious level, in order to reduce it. The therapist also would clarify the reality of the treatment situation, reducing the patient’s misconceptions of their relationship and acknowledging his or her potential contribution to the patient’s misconceptions. The therapist also must be alert to the degree to which the negative development in the transference might correspond to parallel negative interactions in the patient’s external environment, to highlight them, and to attempt to reduce them in parallel to the reduction of the manifest negative transference in the treatment situation.


For example, one patient who presented significant difficulty in maintaining his erection during intercourse with his girlfriend assumed that I, in trying to obtain detailed information of the circumstances under which the patient would lose his erection, was being ironic and evinced an attitude of superiority, implicitly making fun internally of the patient’s difficulty in his sexual life. The patient felt that I was questioning his manliness. As this became quite evident to me, I confronted him with the fact that this was a fantasy on his part and that as far as I could tell, there was no questioning in my mind of his masculinity, only an effort to find out what might be inhibiting him. This led to him talking about his parents’ extremely critical attitude about his masturbatory behavior. I did not explore any further the evident transference implication of his fear of my critique but further explored in what way this fearfulness might have something to do with what happened to him in the relationship with his girlfriend. The patient then told me that when he would lose his erection she would smile, and he felt that she was looking down on him, not considering him fully as a man. He saw in her the same attitude he attributed to me of devaluing him because of his sexual difficulty. At that point, I told him that it seemed to me the most reasonable way to think of this was that she herself might feel insecure because she might feel that she was not able to attract him sufficiently for him to maintain his potency and that she might interpret his difficulty as if it reflected her insufficiency as a woman. The patient confirmed this, saying that occasionally when he had difficulty in achieving an erection and she had that same smile, it was true, now that I mentioned it, there was something helpless regarding that smile in her expression. Thus, the combination of exploration, “reduction” and “export” of the manifest negative transference complemented the utilization of a predominantly positive transference in carrying out this supportive technique.


ABANDONMENT OF TECHNICAL NEUTRALITY


Insofar as the therapist uses cognitive information and affective support, he or she is no longer in a position of technical neutrality and may at times clearly indicate to the patient what might have been a more appropriate behavior on the patient’s part, or what indeed, in the therapist’s view, was an inappropriate reaction of the environment, to which the patient reacted frightfully. One problem with this approach is the risk of infantilizing the patient by providing the patient with an excess of advice giving or guidance, thus bypassing the patient’s responsibility for his or her own behavior; additionally, there is a risk that the abandonment of technical neutrality may foster countertransference acting out.


COUNTERTRANSFERENCE UTILIZATION


The therapist’s ongoing internal explorations of countertransference reactions to the patient and to the specific transferences enacted in the treatment situation are crucial elements of the treatment, guiding the therapist in his or her reaction to the positive and negative transference developments and providing him or her with ongoing information about affective dominance in the therapeutic hours. This is an important component of the priority setting of interventions. In essence, countertransference exploration in SPP does not differ from its use in TFP (Yeomans et al. 2015).


CONFRONTATION OF PRIMITIVE DEFENSIVE OPERATIONS


The predominance of splitting-based defensive operations in severe personality disorders emerges clearly in the treatment developments of patients with borderline personality organization. Pervasive acting out, dissociated affect storms, severe paranoid transference developments, and somatization, all related to primitive defensive operations, also threaten the social survival of these patients and, not infrequently, the very continuity of the treatment.


Here, a reality-oriented, predictive discussion with the patient of the risk that his or her present reactions or planned behavior entails may directly address the potential consequences of behavior based on severely distorted assessment of internal and external reality. For example, a patient’s provocative challenging behavior under the effects of projective identification may be reduced by pointing out the self-fulfilling risk of such behavior, the need for him or her to be alert to others’ motivations that may not be related to the patient, alerting the patient to his or her demonstrated proneness to attribute negative intentions to the reaction of others.


One patient mentioned her frequent reactions with crying spells to critical observations of her supervisor at work. I became concerned with the effects of this behavior on the evaluation of her work performance. My pointing to her denial of the potential negative consequences of her emotional outburst at work (i.e., the threat of being fired as such regressive behaviors accumulate) helped her to exert more control over these outbursts, without my attempting to explore the patient’s deeper unconscious wishes to provoke the supervisor and to be mistreated in turn. Another narcissistic patient’s repeated tendencies to idealize women who then “disappointed” him after a few weeks could be “slowed down” by exploring the price he was paying for his desperate search for the “perfect” woman.


A supportive psychotherapeutic approach cannot bring about a fundamental change in a patient’s capacity to love, but it can reduce the destructive effects of the denial of this emotional limitation. The general aspect of the technique of confronting primitive defensive operations may be defined as a “common sense” approach to the patient’s characterological behavior pattern while respecting the unconscious roots of these defensive operations and their chronic and repetitive features. It is an effort to strengthen the adaptive behavioral potential of the patient by increasing his or her awareness of the destructive effects of the repetitive problematic behavior.


So far, we have discussed the application of the derivatives of basic psychoanalytic techniques within a supportive psychotherapeutic treatment. In the next subsection, we describe the specific supportive techniques that complement this treatment.


SUPPORTIVE TECHNIQUES


Supportive techniques include cognitive information and support, affective support, facilitating emotional abreaction, and direct or indirect interventions in the patient’s social reality by means of orientation and advice to the patient or to auxiliary caregivers. When indicated, third persons involved in providing the patient support outside the sessions may be activated and their work reinforced. The therapist should feel free to interact directly with others in the patient’s life if that seems indicated in terms of the overall strategy of the treatment, the general condition being that the patient either participates or is completely informed of the therapist’s intervention with such third parties.


Supportive techniques involve ongoing detailed monitoring of the patient’s life tasks, the completion of the recommended tasks set up in the treatment situation, and his or her participation in expected collaborative ways with the therapist’s effort. All these supportive techniques relate directly to the initial contract setting, the conditions for limit setting, and identifying specific tasks that the patient is expected to carry out as part of the treatment arrangements.


Treatment Tactics


ASSESSMENT


An essential aspect of our supportive psychotherapeutic approach is a careful, detailed evaluation of the patient’s present personality, mapping out all the symptoms, difficulties, and problems that the patient may have in any areas of living. We also try to obtain information about his or her physical condition, medical history, and ailments, and assess the responsibility that the patient takes toward his or her physical health. The method of structural interviewing that we have developed as part of TFP applies perfectly to the initial study of patients who will enter a supportive psychotherapeutic treatment.


ESTABLISHING PRIORITIES OF OVERALL INTERVENTIONS, PROGNOSIS, AND LIMITATIONS OF THE TREATMENT


It is essential to make a realistic assessment of what the patient’s possibilities are and what his or her limitations are, and to have a full discussion with the patient regarding what in the therapist’s view the patient can expect from the treatment. The patient’s responsibilities in participating with the work of the treatment and under what conditions the treatment may achieve the desired changes should be clarified and agreed on. Later, under conditions of severe acting out, particularly with problems regarding the continuity of the treatment and risks of premature disruption, these initial discussions and clarifications may become useful in reminding the patient—again and again, if necessary—what the reasons for the treatment are and under what conditions the treatment may succeed.


On the basis of all the information initially obtained, the therapist may establish general priorities for his or her interventions, and these overall treatment tasks determine important criteria for interventions that are combined in each session with the priorities derived from the momentary affectively dominant subjects. In contrast to TFP, the highest consideration in SPP for the therapist’s interventions is no longer only what is affectively dominant but a combination of such affective dominance and general treatment priorities.


CONTRACT SETTING AND TREATMENT FREQUENCY


The general conditions of treatment, its frequency, and ways of dealing with missed sessions should be discussed at the outset. Supportive psychotherapy may be carried out on a once-per-week basis but also at a higher—or lower—frequency. The consistent adherence to a predetermined minimal frequency becomes even more important than in TFP with its higher frequency.


FREE ASSOCIATION


The patient should receive instructions for carrying out modified free association. In practice, we tell the patient that in each session he or she should feel free to bring in whatever is worrying him or her most at that point, how his or her present difficulties are evolving, and, if there are no important issues on his mind, to talk freely about whatever emerges in the patient’s mind in the session itself. In other words, the patient is instructed not to come with a fixed agenda while still being invited to talk freely about whatever worries he or she wants to bring up. The general intention is to help the patient come as close as possible to carrying out free association, knowing that it will be limited by pressures from the patient’s immediate reality issues as well as by the therapist’s selective interventions in terms of the therapist’s own criteria.


SELECTED FACT


As mentioned previously, the therapist’s criteria for intervention include the combination of the priorities for the treatment set at its initiation and the presently affective dominance, which are derived from the patient’s verbal communication, nonverbal communication, and the countertransference that emerges in the session itself. From a practical viewpoint, the following are frequently competing priorities in the interventions of supportive psychotherapy:



  1. Urgent issues in the patient’s work or profession, determining his or her “social survival”
  2. Problems in the patient’s physical care, including the patient’s not dealing appropriately with illness and his or her difficulty with preventing medical complications—in other words, “physical survival”
  3. Problems in the patient’s intimate relations, or “relationship survival,” an area particularly difficult because of the limitations in supportive psychotherapy in affecting the patient’s subjective, emotional reactions to partners and sexual objects in general.1
  4. Control of aggression against the self or others, or “control of self-destructiveness,” which becomes particularly relevant in patients with severe, chronic self-mutilation.2
  5. Control of antisocial behavior, or “legal survival” (may become an urgent task of the treatment)3

TRANSFERENCE MONITORING AND MANAGEMENT


As mentioned earlier, it is important to be alert to and to ventilate manifest negative transference to restore or maintain a workable positive transference relationship; this may take an extended time in some patients with very severe personality disorders who have already failed to respond in previous psychodynamic and cognitive-behavioral treatment models. Sometimes, open defiance and challenge dominate the sessions, and the patient may triumphantly confront the therapist with his or her assumed incapacity to help the patient. The reality-oriented reduction of manifest negative transference may include the therapist’s pointing out repetitive aspects of the patient’s behavior that replicate his or her conscious behavior toward others in the past. It is a clarification and deflection of the transference that is perfectly commensurate with a supportive approach. Under these circumstances, the main task is to discuss the situation in realistic terms, fully and patiently. It is important that the therapist be open, direct, tactful, and honest in his or her communications and not attempt to artificially foster a “therapeutic alliance.”


Sometimes the task is to explore systematically with patience and respect for the patient all the reasons for the patient’s convictions that he or she cannot be helped and that lead the patient to oppose actively all the interventions of the therapist. At times, it is helpful to make it very clear to the patient that, in effect, if the patient, for whatever reason, persists in rejecting everything that comes from the therapist, the treatment will not help. Acceptance of the fact that the treatment may not help the patient without manifestations of negative countertransference reactions or a sense of failure on the part of the therapist may help. To the contrary, the therapist’s internal, tranquil acceptance that the treatment may not work, while still being interested in the possibility of studying whether something might still make it work despite everything, would reflect the therapist’s appropriate way to deal with a rejecting onslaught.


It may become necessary for the therapist to also convey his or her questioning attitude regarding whether this treatment will be helpful to the referral source, the patient’s family, and/or any third party that would appear to exert pressure on the therapist to help the patient despite the patient’s consistent rejection of help.


In other words, the therapist needs to be in emotional control of the situation, rather than under the combined pressures of therapeutic expectations from the social environment and an active opposition of the patient, who has the fantasy that he or she is defeating the therapist by resisting the treatment. The therapist may use selective communication of aspects of his or her countertransference reaction as part of the therapeutic intervention, if that would serve to reduce the emotional distortions the patient is inducing in the interaction, as part of the therapist’s effort to reduce the intensity of the negative transference and to facilitate an improvement in the immediate therapeutic interaction.


This would seem a perfectly appropriate way of using one’s countertransference under extremely negative conditions in an initial evaluation, but it raises the risk of the patient’s exploiting this way of obtaining information about the therapist by escalating his or her own negative reactions. Accusations of the therapist’s hostility, indifference, callousness, and so on may serve this purpose; therefore, the therapist must limit carefully such countertransference communications where they serve the obvious purpose of the patient’s exercise of omnipotent control. While countertransference communication generally would not be indicated in supportive psychotherapy, selected communication of countertransference reactions either to deal with severe manifest negative transference or as part of a focused re-educative approach on the part of the therapist may be indicated, as long as the therapist is aware of the risks of the patient’s exploiting this communication in the transference.


Under ordinary circumstances, in which, at least on the surface, there seems to be no urgent problem that requires immediate intervention regarding any aspect of the patient’s external reality and positive transference manifestations seem affectively dominant in the session, the ventilation of the conscious aspects of the transference may be indicated. This includes the therapist’s acknowledging the patient’s good feelings toward him or her while realistically reducing excessive idealizations that increase the patient’s feelings of inferiority and incompetence, and thus contributing to mitigation of the severe splitting processes that are typical of patients with severe personality disorder. There are other times in which, despite presence of transference manifestations in the hour, the urgency of a conflict in external reality may deter the therapist from bringing up the transference at that point unless it can be linked at a conscious level with the urgent issue enacted in the external environment.



THE THERAPIST’S RELATIONSHIP WITH THE EXTERNAL ENVIRONMENT


The degree to which the therapist requires information about the patient from the external environment in SPP is variable. There are patients who have no antisocial features and are honest and direct in reporting what is going on in their environment, and the therapist has a realistic feeling that he or she has a good sense of the ongoing developments in the patient’s life. In other cases, particularly with patients who present severe antisocial features, who are dishonest, withhold information, or frankly lie, it may be indispensable to maintain an ongoing contact with family members or other important people in the patient’s life. The therapist must make the decision as to what extent he or she needs to have periodic contacts with third parties to obtain information about the patient’s life outside of sessions. This is a crucial aspect of the treatment of certain patients and must be made an indispensable condition for the treatment to take place. The treatment may stand or fall on the patient’s authorization to the therapist for maintaining such a contact. As mentioned earlier, if such contacts are available and used freely, it is important to keep the patient fully informed and not to do anything for which the patient has not given full consent.


This issue is particularly relevant with adolescents with personality disorders, in which an open communication with parents, school, and other authorities must be shared with the patient. Assuming outpatient treatment is the appropriate level of care, it is important for the therapist to keep in mind that the adolescent patient’s aggressive behavior toward others or self should, in theory, be or come under the patient’s control, whereas the patient’s subjective feelings of love and hatred cannot be manipulated behaviorally. The patient must be free to feel whatever he or she feels, but the patient is also responsible for his or her behavior, and this continues to be true throughout the entire treatment.


A prominent problem encountered in SSP is the presence of secondary gain of illness, a prognostically negative feature that is often, but not always, coupled with severity of antisocial behavior, another prominent problem seen in the context of severe personality disorders. Either of these features bodes ill for successful treatment, the more so if they are found to be co-occurring. It is important for the therapist to attempt to control and eliminate secondary gain as far as is possible. Secondary gain is involved most frequently in exploitation of the patient’s family and/or state and social service agencies. The therapist may be of help to the family in reducing exploitation by the patient by being very direct in expressing his or her views and recommendations in this regard, again, with full awareness on the patient’s part of what the therapist is doing. In the case of patients who obtain chronic subsidies from state or other social service agencies, it may be more difficult for the therapist to intervene, and patients may successfully exploit such systems under the erroneous assumption that severe personality disorders limit or contraindicate the possibility of work or studies.


It is important for the therapist to keep in mind that there is no reason why a patient should be declared unable to carry out ordinary work or studies because of a personality disorder. This is a general principle that may run against conventional understandings in certain subcultures and may provide a social reality militating against the possibility of treatment. There are cases in which the patient’s passivity, supported by a long-standing external supportive declaration of his or her incapacity to work, maintains him or her in an inactive condition that serves as an obstacle to overall improvement. At a certain point, this societal or familial undermining of the patient’s potential will limit what can be expected from the treatment and even may end the treatment.


One alternative to ending the treatment under such negative circumstances is the consideration of the patients as “lifers.” If treatment continues, expectations must be sharply reduced. The treatment now requires a shift toward accepting the patient’s limitations, with the therapist complementing social support by providing the patient with advice, prescribing medication if indicated, and fostering the patient’s ability to make the best of what his or her life situation and personality permit. This treatment may be carried out at a reduced frequency—for example, once or twice per month—geared to deal with immediate life problems for which the patient may require and be able to benefit from some help, but without any further attempts to change the overall nature of the equilibrium between acting out of unconscious conflicts and the predominant defensive operations that maintain the status quo. It is desirable, if such a state of affairs is reached, to make very clear that the patient is being maintained in a chronic supportive counseling status that is not to be confused with the very active treatment ordinarily implied in SPP.


THE PATIENT’S RESPONSIBILITIES


A central aspect of SPP is the establishment of specific goals that focus on improving the patient’s functioning in the major areas of his or her life: work and profession, love and sex, social life, and creativity. Realistic goals derive from the patient’s potential, from his or her external reality, and, very importantly, from the therapist’s expectations and confidence in what this patient might achieve if he or she were not limited by his or her characterological illness. These overall objectives may translate into complex tasks that must be fulfilled for their achievement, such as the patient returning to work, obtaining additional education or training, or completing or returning to school. In the interpersonal realm, treatment goals might involve, for example, the patient learning to function independently, learning ways in which serious conflicts in the relationship with a partner can be managed and crises avoided. The therapist’s own life experience and his or her technical expertise and full, detailed assessment of the patient’s present personality are crucial determinants in setting up concrete treatment goals and tasks for which the patient has to take responsibility. Supportive psychotherapy, therefore, is always a joint effort, a joint task, and not something that the therapist is doing while the patient is the passive recipient of it.


For example, one adolescent patient with an infantile personality disorder, less than average intelligence, chronic school failure, sexual promiscuity, and drug abuse assumed that her limited intellectual capacities would never get her through college. She was interested in becoming a nurse but thought she would never be able to achieve that. After discussing with her the nature of her intellectual difficulties and the fact that this meant that her efforts would have to be much greater than those of people for whom intellectual tasks came much easier, I insisted that she might be able, if she worked hard, to achieve a college education. She did enter college with the financial support of her parents, and during the treatment managed to do the very hard work that permitted her to successfully complete a college education. The confidence of the therapist that, given the right motivation, she would be able to do the very hard work necessary to keep up with college demands despite her intellectual limitations seemed a crucial feature in this case.


At the same time, it became clear that the sexual promiscuity of this patient involved an infantile effort to obtain a boyfriend, a dependent wish to fight off loneliness. We addressed, without exploring the profound masochistic features of her personality, how she would have to proceed about finding a boyfriend who might be interested in her beyond simply having sex on a few occasions. This became possible by “forcing her” to carry out hard studies while stimulating her openness and freedom in relating to men, which helped her to develop better criteria about who would be more acceptable and thus improved both of these areas of major difficulties. In the process, I also obtained her compliance with the strict requirement that she stop the use of all drugs (“You won’t be able to make it in college while high on drugs”). A subtle but clear erotic transference was not explored, except in the indirect approach of reducing her guilt feelings related to her sexual life. This patient became used to the fact that, at least once a month, I would discuss with her in great detail her grades, difficulties in studying, and the number of hours she had spent doing the work. It became clear to her that therapy became another subject in which she had to perform in order not to fail. Her reward was the sense that the therapist shared with her the triumph around every grade and class that she successfully mastered.


In short, setting up of realistic tasks and ongoing monitoring of these tasks, together with attention to what is affectively dominant in the sessions, determines the priority of interventions in the therapeutic hours and summarizes the tactical approaches for this kind of treatment.


Overview of General Indications, Contraindications, and Frequency


As mentioned previously, SPP would be indicated for the lightest and the most severe cases of personality disorders, particularly for the very severe patients, in which various contraindications may be present regarding carrying out TFP such as practical impossibilities of treatment beyond one session per week or a history of no response to a broad spectrum of both psychodynamic psychotherapies and cognitive-behavioral therapies. At our hospital, we quite frequently see patients who have been treated with the usual type of generally supportive-expressive psychodynamic psychotherapy, TFP, mentalization-based therapy, dialectical behavior therapy, or cognitive-behavioral therapy. Usually, the severity of patients’ aggression, severe antisocial features, uncontrollable secondary gain, and destructive factors in the family or the social environment contribute to these negative developments, and supportive psychotherapy along the lines mentioned here might become the treatment of choice or considered as a treatment of last resort.


The objectives of SPP are highly variable, from efforts to bring about radical improvement, to chronic support that is individually tailored, to the possibility of an alternative, final shift into maintenance counseling for “lifers.” The antisocial personality proper represents, in our experience, a contraindication for any kind of psychotherapeutic treatment, but there are cases in which it is not clear whether this diagnosis can be confirmed at the beginning of the treatment. SPP may represent a diagnostic trial under such uncertain circumstances to explore the possibility of whether the patient still can be helped. Some patients with uncontrollable secondary gain may be started in treatment with the understanding and agreement that elimination of that secondary gain is a treatment goal. The patient’s capacity to work collaboratively toward that goal will provide an answer as to whether he or she still might be helped with SPP. Finally, there are patients who, without presenting an antisocial personality proper, suffer from antisocial behavior that interferes to such an extent with honest communication in the therapeutic hours that a psychotherapeutic approach becomes practically impossible.


As mentioned before, SPP may be carried out on a once-per-week basis. The basic rationale for this position is that, insofar as the transference is not expected to be fully deployed and systematically interpreted, supportive measures may be employed quickly to deal with major crises and urgent life problems. We try to help the patient to manage his or her ongoing conflicts while monitoring his or her capacity to do that by ongoing review of the accomplishment of the jointly agreed-on tasks or the failure to achieve them. Supportive psychotherapy based on these principles may be carried out at a higher frequency. The question then arises as to whether this might not be an indication, after all, to attempt to change personality more radically using TFP proper.


Comparison of Supportive Psychodynamic Psychotherapy and Transference-Focused Psychotherapy


It may be helpful to summarize commonalities and differences between these two related treatments. Both TFP and SPP are based on an equally extended, in-depth diagnostic evaluation, with a crucial mapping out of all the patient’s life problems in the different areas of the patient’s functioning. Both treatments attempt to establish priorities of interactions that need to be explored and potential limitations given the nature of the pathology, the patient’s personality, and the treatment situation. Both treatments have as major prognostic limitations the negative effects of secondary gain and antisocial features, particularly patients’ dishonesty, that may limit the capacity for the therapist to contain the total therapeutic situation.


Major differences between these treatments include the following: In SPP, the need for information about the relations with the external environment becomes maximal, much greater than in TFP. Within the treatment sessions, SPP has a more complex set of priority of interventions in each session. In TFP, affective dominance is the main criterion for priority setting, except under certain well-defined emergencies. In contrast, in SPP, the therapist needs to be aware of affective dominance as well as how the patient is carrying out the major treatment tasks, and what the present emergencies in his or her real life are (i.e., the “survival” issues). The interference in the sessions by the enactment and acting out of manifest negative transference needs to be reduced and/or deflected. SPP may require faster decision making and crisis intervention, and any disruption, such as a cancellation of sessions for whatever reason, creates a longer and more risky gap in the treatment.


SPP requires the therapist continuously to evaluate what has been learned and what has changed from session to session and to recognize when the therapy is at risk because basic conditions for carrying it out have been affected. SPP is very much geared to improve the patient’s functioning but is not invested in basic personality change. Intense consultations involving external reality and monitoring of the patient’s tasks and difficulties tend to eliminate technical neutrality, an essential aspect of supportive psychotherapeutic treatment that creates the danger of countertransference acting out and patients’ infantilization. Patient and therapist will have to assess and live up to “common sense” to a maximum in SPP, and the therapist must be aware of the risk that his or her own value system may pose in the areas of ethics, sex, religion, and so on. The direct environmental intervention by the therapist also differentiates SPP from TFP.


Finally, there are basic similarities between SPP and TFP, namely, the ongoing monitoring of the transference, and even the selective management of potential role reversals in the transference in SPP, so long as the general rule of lack of transference interpretation is followed. Both these treatments are characterized by intense and sophisticated monitoring of countertransference and by the awareness of the dominance of splitting mechanisms in the case material. In SPP, the therapist partially accepts splitting mechanisms in the sense of the patient’s identification of the therapist with a positive segment of internalized object relations while still encouraging the patient’s reducing excessive idealization on the one hand and accepting the reality of manifest aggression in the transference on the other. This reduction of inappropriate idealization and limited tolerance of manifest aggression in the transference reduce the dominant primitive defenses based on splitting mechanisms.


References


Gill MM: Psychoanalysis and exploratory psychotherapy. J Am Psychoanal Assoc 2(4):771–797, 1954 13211443


Kernberg OF: Psychoanalysis, psychoanalytic psychotherapy and supportive psychotherapy: contemporary controversies. Int J Psychoanal 80(Pt 6):1075–1091, 1999 10669960



Kernberg OF, Burnstein E, Coyne L, et al: Psychotherapy and psychoanalysis: final report of the Menninger Foundation’s Psychotherapy Research Project. Bull Menninger Clin 36:1–275, 1972


Kernberg OF, Yeomans FE, Clarkin JF, et al: Transference focused psychotherapy: overview and update. Int J Psychoanal 89(3):601–620, 2008 18558958


Rockland LH: Supportive Therapy for Borderline Patients: A Psychodynamic Approach. New York, Guilford, 1989


Yeomans FE, Clarkin JF, Kernberg OF: Transference-Focused Psychotherapy for Borderline Personality Disorders: A Clinical Guide. Washington, DC, American Psychiatric Publishing, 2015


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Mar 29, 2020 | Posted by in PSYCHIATRY | Comments Off on A New Formulation of Supportive Psychodynamic Psychotherapy
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