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22. Psychological Treatments: The Patient
Keywords
Supportive psychotherapyCognitive-behavioral therapyPsychoeducationChronic disease managementPositive psychologyResilienceCopingEssential 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.
Supportive therapy has these goals: ameliorate symptoms, reduce anxiety, and increase self-esteem, adaptive skill, and psychological function.
Cognitive-behavioral therapy (CBT) for psychosis is an evidence-based ancillary treatment that teaches patients to think about their symptoms in ways beyond the broken brain paradigm in order to manage them more effectively through mastery.
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 on their own by increasing knowledge about the disease. In medicine, this empowering approach is known as chronic disease management. It allows patients to manage disease like diabetes or cancer without relying only on professional help.
Being resilient is not only a genetic and fixed attribute but something that was also shaped through life experience. We can become more resilient by learning new ways of coping with stress.
“A sense of a wider meaning of 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) [1]
Simply dispensing antipsychotics, while treating the brain, does not treat the mind and soul of patients. In this chapter, I discuss supportive therapy, cognitive-behavioral therapy (CBT), psychoeducation, and resilience training as psychological treatment modalities appropriate for most patients with schizophrenia. The choice of therapy hinges more on availability than on research which does not tell us if supportive therapy, for example, is superior to CBT or psychoeducation [2].
Currently, psychological treatment for patients with schizophrenia is typically offered as individual therapy even though group therapy is a powerful modality that is widely used in other contexts. For example, behavioral treatments like social skills training and family psychoeducation have traditionally been provided in group settings in order to harness the power of groups where patients and families learn from and support each other. For the same reasons, smoking cessation groups are preferred over individual smoking cessation counseling [3]. Medicine has started to experience with group visits (e.g., in diabetes care [4]), something that would be interesting to explore further for our population as well.
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. I was once asked if I was Freudian or Jungian which does not reflect my clinical reality in public and community psychiatry. (I greatly respect both Freud who was a pioneer but particularly Jung who treated patients with serious psychiatric illnesses on his clinic days and whose writings contain much clinical wisdom, particularly as you head into the second half of your career.) That does not mean that the subjective patient experience is unimportant and that in higher-functioning patients, elements from other therapies to address demoralization and existential suffering (the being-thrown-into-this-existence, Heidegger’s Geworfenheit) could not be used. I have found elements from existential therapies (e.g., Viktor Frankl’s logotherapy) very applicable, but you might find other philosophies suit you more (see also Chap. 30, on depression and suicide, and the article on religion and spirituality in schizophrenia, cited in the Additional Resources). Family psychoeducation is covered in the next chapter (Chap. 23), social skills training and cognitive remediation are covered in the chapter on cognition (Chap. 29), and avatar therapy is covered in the chapter on refractory psychosis (Chap. 12).
Supportive Therapy
In some circles, “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 [5]. 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 psychological functioning of patients (e.g., those with primitive defense mechanisms).
Supportive therapy contains specific elements that can be taught and fruitfully applied in clinical encounters. Supportive therapy is not merely meeting with a patient and being seemingly supportive by letting him vent – this is a caricature of what supportive therapy entails. Instead, 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 patients (“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, however, 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. In supportive therapy you are first and foremost a “real person” for the patient (as opposed to an object of projection). As the expert, you might not have all the answers, but recommendations and suggestions, even some nudging, are helpful, too.
The talk in supportive therapy is conversational and natural. Avoid pauses that become uncomfortable. Talk about what you know: sports and family. To the uninitiated, this seems like chitchatting. If 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 (see below, in the positive psychology section). Focusing on areas of strength and pride (a patient might not work but 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 like a hospitalization.
The use of medications is acceptable (probably the norm) in supportive therapy and an important tool to decrease anxiety and other unpleasant affects. However, learning how to tolerate unpleasant affects that stem from unalterable situations without the use of medications is a long-term goal for all but the most impaired patients.
Goals and Techniques
Goals of supportive therapy
1. Ameliorate symptoms |
2. Decrease anxiety |
3. Enhance the triad of self-esteem, adaptive skill, and psychological function (ego function) |
These three goals define the boundaries with more insight-oriented therapies, in which the objective is to gain insight into habitual ways of experiencing people and approaching the world, followed by change. In supportive psychotherapy, psychological insight is not a primary goal and not seen as a prerequisite for change. Because psychological change is not an objective (increased adaptive function with who people are, not what they may become is), shore up healthy defenses and do not challenge defenses.
Supportive techniques are direct and self-explanatory; you will offer praise, encouragement, reassurance, and even advice and instruction [7]. You will find yourself asking for clarification if patients are confusing in their utterances or confused about their experiences. Helping patients to rename experiences can subtly move patients to accept a different view of events (reality testing). Setting limits and encouraging positive behaviors are other elements that are frequently used.
Clinical Vignette
Helga is a 45-year-old woman who has long-standing schizophrenia. She lives alone in an apartment a few houses away from her elderly mother, who was just in the hospital for an acute respiratory illness. You see Helga every other month when she comes for her clozapine clinic visit. Today, she is wearing new glasses.
One of the first things you might comment on is her new glasses. “I have not seen these glasses before, are they new?” The patient proudly affirms this, “Yes, I picked them out myself.” In supportive therapy it would be acceptable to praise the patient, “These look nice on you. You really picked well.” This shows you approval and might enhance the patient’s self-esteem. It would then be very appropriate to talk about the health of the patient’s mother. Saying “I heard your mother was in the hospital. How is she doing?” shows concern and helps with anxieties that the patient might have about her mother’s illness. You could give direct advice: “How about going over to her house and cooking some soup for her?” If the patient describes insomnia related to worrying about her mother, adding a sedative to decrease anxiety and to help with sleep is appropriate (as opposed to focusing on the existential questions that the mother’s illness might have provoked although in patients with better ego function addressing such fears may be appropriate).
Simply being natural and stating the obvious (in this example, new glasses, concerns about mother’s illness) is an essential ingredient in working with patients who suffer from schizophrenia. Some self-disclosure is another ingredient that keeps you real but may not come natural to some clinicians, particularly if they are fearful of boundary violations learned in psychotherapy.
Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT), originally developed as a treatment for depression, is an evidence-based treatment for psychosis that is routinely included in treatment guidelines for schizophrenia. Unfortunately, because the main impetus for developing CBT for psychosis has come from research groups in Great Britain, it can still be very difficult to find practitioners in the United States who can competently use CBT to treat patients with schizophrenia. However, you can easily integrate some principles of CBT into your own routine clinical care, particularly if you limit yourself to addressing a few specific symptoms [8].
CBT has several features that make it an attractive treatment modality. The reductionist and simplistic view of schizophrenia as a “brain disease” is rather pessimistic (and wrong) since it does not take into account the influence of environment and the relative frequency of psychotic symptoms in community samples. Van Os and others have argued strongly for a continuum model of psychosis [9]. CBT tries to help patients develop a view of their disease that goes beyond a “broken brain” model of “madness” and, in doing so, broadens views of how symptoms come about and what can be done about them. For example, normalization of psychotic experiences may reduce stigma.
Key Point
CBT for psychosis makes several assumptions. For one, symptoms are conceptualized as brought on by the combined result of vulnerabilities (which could be biological, social, or psychological) and stressful life experiences. In this view, psychosis is seen as understandable and “normal.” Symptoms are then thought to be maintained by counterproductive appraisals and behaviors which can be identified and changed. The CBT therapist identifies operative reasoning biases and challenges them through such techniques as cognitive restructuring or behavioral experiments. Examples of these biases include selective data gathering, jumping to conclusions, and overconfidence.
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