Psychologic Treatments—The Patient

Essential Concepts

Supportive therapy is the pragmatic, real physician trying to help patients in the here-and-now with encouragement and advice. The foundation of supportive therapy is a good alliance with your patient.
Cognitive-behavioral therapy (CBT) for psychosis is a promising ancillary treatment that tries to teach patients an alternative view of their symptoms and more effective coping strategies.
Principles of CBT for psychosis can be easily integrated into treatment to address residual positive and negative symptoms not ameliorated by medications.
Psychoeducation tries to improve how patients manage their disease by increasing knowledge.

“A sense of a wider meaning to one’s existence is what raises a man beyond mere getting and spending. If he lacks this sense, he is lost and miserable.”

—C. G. Jung (Der Mensch und seine Symbole (MS 89)/Man and His Symbols)

Simply dispensing antipsychotics, while treating the brain, does not treat the mind and soul of patients. In this chapter, I discuss supportive therapy, CBT, and psychoeducation as psychologic treatment modalities appropriate for most patients with schizophrenia. Psychoanalysis, or insight-oriented psychotherapies, when used alone is an inappropriate and woefully inadequate approach to treat schizophrenia, but you might see the occasional family still ask about psychoanalysis. That does not mean that in higher-functioning patients, elements from other therapies to address demoralization and existential suffering (the being thrown into this existence, Heidegger’s Geworfenheit) should not be used. I have found elements from existential therapies (e.g., Victor Frankl’s
logotherapy) very applicable, but you might find other philosophies suit you more (see also Chapter 28, on depression and suicide, and the article on religion and spirituality in schizophrenia that is cited in the Additional Resources).

SUPPORTIVE THERAPY

“Supportive therapy” has a bad reputation, indicating that since nothing specific can be offered, one resorts to being merely supportive as opposed to attacking “root causes” in dynamic therapies. Apart from the questionable claim about the efficacy of many psychotherapies, at least for more severe disorders, supportive therapy is a useful treatment in its own right; in fact, most physicians in other specialties practice it all the time. Some might even argue that supportive therapy for patients with schizophrenia is one of the more demanding skills because of poor psychologic functioning of patients (e.g., those with primitive defense mechanisms).

I think of supportive therapy as a pragmatic encounter with the patient, focusing on today’s problems (“hic et nunc— here and now”) and how to solve them. If you want to get technical about supportive therapy, think of supportive therapy as the kind of therapy in which you benevolently use the good relationship (or positive transference) that you might have with your patient (“Yes, Doc, whatever you think is right for me”). It is rather difficult to be useful in the long run if your patient does not like you (which will happen). In supportive therapy, the topic of interest is not the transference or countertransference; be aware of, but do not interpret transferential issues. You know that you are doing something wrong if your patients leave the office more anxious than when they came in. You are a “real person.” As the expert, you might not have all the answers, but recommendations and suggestions are helpful, too.

The talk in supportive therapy is conversational and natural. Avoid pauses. Talk about what you know: sports, family. To the uninitiated, this seems like chitchatting. In fact, you are doing a mental status examination, and you determine how much life the patient has other than being a professional patient. In patients you follow for many years, focusing only on areas of weakness and psychopathology is counterproductive. Focusing on areas of strength and pride (a patient might have great knowledge about baseball) serves the all-important purpose of fostering a good treatment alliance. A good
alliance is the one thing that might save you when you have to make tough choices.

The use of medications is acceptable in supportive therapy and an important tool to decrease anxiety and other unpleasant affects.

Goals and Techniques of Supportive Therapy

You can look at three goals of supportive therapy:

Ameliorate symptoms
Decrease anxiety
Enhance the triad of self-esteem, adaptive skill, and psychologic function (ego function)

These three goals define the boundaries with other therapies, in which personality change is the objective. In supportive psychotherapy, psychologic insight is not a primary goal and not seen as a prerequisite for change. Because psychologic change is not an objective (instead, increased adaptive function with what people have), shore up healthy defenses and do not challenge defenses.

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