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24 Cards in this Set

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  • Back
Basic Principles of Supportive Psychotherapy
Winston, et.al

Supportive therapy is a treatment that utilizes direct (advice giving, guidance, etc) measures to ameliorate symptoms and maintain or restore self esteem, ego functions and adaptive skills.

Main areas of focus;
Self Esteem
Ego Functions
Adaptive Skills
Indications for Supportive Therapy
(Goldstein)

To main groups for which supportive therapy is indicated;
Crisis- Acute illness, substance abuse, bereavement, adjustment disorder
Chronic illness with impairment of adaptive skills and psychological functions

May be used for people with chronic environemtnal stress

Character disorders - middle to low functioning end of spectrum

For persons whom insight oriented therapy has repeatedly failed.

Persons with poor frustration or anxiety tolerance and limited capacity for self observation
For patients where goal of therapy is to ameliorate symptoms and prevent relapse of major illness

For patients who have significant impairment of ego functions; cognitive abilities, reality testing, thought process, capacity to organize behavior, affect regulation, and the capacity to make relational contact with others. All do to ego deficits and defects

Causes of the impairment include major mental disorders, pervasive development disorder, sever borderline personality disorder, limited intelligence, and limited education or socialization

Menninger Study showed it could be used effectively with higher functioning patients

Persons forced to come - court mandated, spouse
Goals of Supportive Therapy
(Winston)

To stop regression rather than promote it

Conscious problems/conflicts are addressed and goals are to support patient's adaptive defenses. Defenses are only questioned when maladaptive

Transference is usually not addressed. Pos. feelings towards therapist are accepted without interpretation. Only negative transferences are addressed to preserve alliance

Positive events in therapy relationship are offered as examples for problem solving of real life situations presented in therapy.

Therapists also focuses on daily activities, medications, and use of resources for rehabilitation
Supportive Techniques
Winston et al

Ego Functions
Reality testing - empathically responding and devaluing projections relating to faulty reality testing

Lessening the strength of projection and pointing out realities in that aren't readily apparent to the patient (fantasies of killing boss "is it worth destroying your own life over?)

Encouragement of positive control of drives

Minimizing the value of immediate gratification

Offering Praise

Direct advice giving

Helping Pt. face certain truths compassionately

Reduction of the reliance on primitive defenses - minimize negativity, paranoia, obsessions, denial, projections
Contraindications for Supportive Therapy
Goldstein

delirium
Organic mental disorders
drug intoxication
dementia
hel-rejectiong complainers
malingerers
Techniques of Supportive Therapy
(winston et al)
Praise - the healthier the patient, the less praise

Reassurance - Normalizing. Be sure what is reassured is realistic. Implementation of literature, research, etc to make educated forms of reassurance

Encouragement - to maintain hygiene, exercise, interact with ppl

Rationalizing and Reframing - helping them view things from a different perspective

Advice and teaching - more teaching than advice. Giving info and leading the patient to make his/her own decisions

Anticipatory Guidance - help the patient consider in advance what obstacles my lay ahead and what potential course of action could prepare for dealing with them

Reducing and preventing anxiety - Reassurance and encouragement are good means to do this.

Naming the problem - may enhance patients sense of control and thus minimize anxiety

Clarification - summarizing, paraphrasing or organizing what the pt. has said. Bringing clarity to issues that are vague or diffuse or disconnected.

Confrontation - of maladaptive defenses. Bring to the pt. attention patterns of ideas, behaviors, or feeling that they have not recognized or avoided and are maladaptive.
Insight/Expressive Therapy
Exploration of inner conflicts. Analysis of transference is key element to understanding the pt's inner life.

In expressive therapy, defenses are identified and examined to determining underlying conflicts that made the defense nessissary

Symptoms are the result of compromise formations between superego and id. Therapy is used to identify conflict and adapt more effective compromise formations.
Indications for Expressive Therapy
Gabbard

For persons with considerable ego strength

Ability to mentalize - the capcity to self reflect and conceptualize what is in other's minds.

Have ability to tolerate anxious and depressed feelings

Motivation to understand oneself/ Psychological mindedness

can have mild reality testing disturbances, but distortions should be within the normal neurotic range

Capacity to think abstractly

Of average to high intelligence, able to have accurate perceptions, and form relationships.
Expressive Therapy Treatment for...
Persons with self-destructive patterns in interpersonal relationships or suffering distress from lack of self acceptance. High personal goals
Goals for Expressive Therapy
(Gabbard)

Resolution of conflict - The aim of expressive therapy is to explore the nature of unconscious conflicts and resolve the symptoms they produce. Conflicts are not regarded as being completely eliminated, but more effective and adaptive compromise formations are instituted (Brenner)
Pursuit of greater truth and self acceptance
guide patients to look at who they are verse who they want to be. May take form that Winnicott noted of differentiating between the false and the true self. Goals of therapy are to live in ones own skin and gain acceptance of the self.
Self Perspective of Therapeutic Goals
Improved capacity to seek out appropriate selfobjects. Goal is to help pt move from using selfobjects in an immature, maladaptive way to more appropriate and mature selfobjects
Object Relations view of Therapeutic Goals
Improvement of relationships as a result of gaining understanding about one's internal object representations and relations. An acquisition of an understanding of how one's internal self and other representations shape interactions with people in the external world. One main goal would be to help patients integrate aspects of themselves that they project onto others outside
Improved Reflective Functioning
Help increase patients capacity to differentiate between an internal representation of someone and the way the person is in external reality. Pt's should also be able to have sense of another person's internal world and recognize that it is different from one's own. The awareness of two separate minds (Fonagy)
Overarching Goals of Supportive and Expressive Therapy
Both aimed at improved functioning

For supportive, the goal is more immediate - to establish or reestablish adaptive functioning as quickly as possible.

Insight oriented - aimed at working to uncover unconscious mental phenomena, fantasies, conflicts, etc.
Reasons for switching from Expressive to Supportive Therapy
(Rockland)

Pt has a serious regression (suicidal, psychotic)

Severe depression or serious threats of harm to self or others

Serious threats to treatment

Massive anxiety in the patient - a little is good, needed for motivation to change. Too much however is not good, impairs treatment. Also may cause too much anxiety in therapist which also hampers treatment
Peebles - Klieger 4 Core Imbalance Paradigms for Treatment
four underlying disturbances to focus on when beginning a new treatment: Conflict, trauma, deficit, character

Ego Functions: RROTDAS(J(AS)
Winston Supportive
Stop regression
support
Symptoms
Conscious Problems
No Transference
Reduce over reliance of Primitive Defenses
Supportive Indications (Goldstein/Menninger)
Forced into treatment
Crisis
Chronic Illness
- Character Disorder
- Substance Abuse
- Low Tolerance

Have to be Realistic Goals - Symptom Relief
Collaborative open environment to change
Gabbard Expressive Therapy
unconscious drives and symptoms
examine purpose of defense
Therapist stance - Neutrality - Equidistance between Id, Ego Super Ego (A. Freud), Anonymous, Abstinence in order to analyze transference
Therapeutic Change in Supportive Therapy
Unanalyzed libidinal positive transferences are probably the single most powerful agent for therapeutic change in supportive therapy.

"transference cure"

Identification with therapist
Insight Oriented Change
Two Main - Relational (Therapeutic Alliance)

Insight (Interpretations)

Working Through (Gabbard)
Shaefer - Working through as a process of analyzing resistances - over and over again through seemingly endless sets of repetitions

Therapist can serve as a container for negative projections
Middle School School
No drives, Libidinal strivings. When they aren't met the child becomes frustrated and then the internal objects are formed and aggression results.

Children are object seeking

Fairbairn, Winnicott, Biliant
Winnicott
Primary Maternal Preocupation - state of mind of the mother towards her newborn. It supports the child's illusion of omnipotence by the mother's keen attunement of its needs such that the child believes that mere desire generations the object or need satiation because the child thought of it. This illusion is gradually reduced through manageable failures.

Antisocial tendency - he saw values in the first antisocial acts as evidence of the chil'ds feeling of having been cheated of what was rightfully his or hers, that is, a reliable pair of parents. Traced the tendency in children whose normal early upbringing had been interrupted in the second or third year of life.

True Self - Develops in an atmosphere of acceptance and care by the good enough mother. Interference with this process may result in the child's withdrawal from authenticity and spontaneity.

False Self - responds to a hostile world that he/she experiences as rejecting of his/her spontaneity with a false self that passes as real.

Good Enough Mother - Offers a holding environment providing and optimal amount of constancy and comfort for the wholly dependent infant. Offers at the "right time" instead of imposing her own timing and needs. Then when the infant must face frustration, aggression and loss she provides support within a setting of ongoing basic empathy and holding.

Holding Environment
Good enough mothering enables the mother to meet the infant's omnipotent needs without having to challenge them overly so that the infant has a gratifying human context for a subjective sense of his or her own being expression and creativity

False Self- if parent is not empathically attuntuned child develops a self that has to please the parent and doesn't really know true self. Can't really identify own affects.

Like Fairbairn, Winnicott conceptualized the psyche of the child as developing in relation to a real, influential parent. For a child to develop a healthy, genuine self, as opposed to a false self, Winnicott felt, the mother must be a "good-enough mother" who relates to the child with "primary maternal preoccupation." Anticipating the insights of Kohut and self psychology, Winnicott felt that a good-enough mother allows herself to be used by the infant so that he or she may develop a healthy sense of omnipotence which will naturally be frustrated as the child matures. Winnicott's theory is especially innovative regarding his conceptualization of the psychic space between the mother and infant, neither wholly psychological or physical, which he termed the "holding environment" and which allows for the child's transition to being more autonomous. This concept of the "holding environment" led Winnicott to develop his famous theory of the "transitional object." Winnicott felt that a failure of the mother -- the not-good-enough mother -- to provide a "holding environment" would result in a false self disorder, the kind of disorders which he saw in his practice. Winnicott's theory of "false self disorders" is uncannily similar to Laing's description of the schizoid personality in The Divided Self. Winnicott also felt that the therapist's task is to provide such a "holding environment" for the client so that the client might have the opportunity to meet neglected ego needs and allow the true self of the client to emerge.