The number of people living as patients in psychiatric hospitals has declined over the last forty years by more than one half, partly as the result of new antipsychotic drugs and as the result of new attitudes toward the mentally ill.
Unfortunately, many of these 300,000 patients have not returned to the community and to their homes entirely cured. They have symptoms still, as do the far greater number of people who have never been in a mental hospital but who are emotionally disturbed nevertheless.
Indeed, emotional and mental illnesses are no less common now than they ever were. Very many people suffer transient emotional disturbances, and there are many whose disturbances are prolonged and profound. Even when these conditions are not severe, however, many of the people affected are unhappy and impaired in functioning. Even though they live at home, the way they live is often unsatisfactory; it also can be difficult for everyone around them, especially for their families. And in most cases, they do not grow less miserable simply by growing older. They need treatment to get better.
The burden of treatment for these troubled individuals, therefore, does not rest in the hands of hospital personnel, if ever it did. Psychotherapy in some form or another is conducted now within the community by professionals and para-professionals drawn from dozens of different occupations and disciplines, including—besides psychiatrists and psychologists—social workers, family doctors, visiting home nurses, welfare workers, probation officers, drug counselors, school counselors, marriage counselors, occupational and recreational therapists, industrial counselors, ministers and other pastoral counselors, and many others.
These various professionals come in contact with emotionally disturbed persons in various ways; but in trying to help them, they must accomplish the same purposes. They try to relieve their emotional distress, and they try to help them to avoid the ineffective and inappropriate behaviors that are a characteristic manifestation of many emotional illnesses.
To do either or both, they must have some understanding of the nature of emotional illness and of the process of psychotherapy. They must understand, first of all, that by virtue of their work, they may not be able to avoid doing psychotherapy. In many cases, psychotherapeutic techniques are part of the process of caring. Therefore, they should learn to do them as well as they can.
The influence of these "collateral therapists" is significant. Through their efforts, they can change the course of an emotional illness and, thereby, the course of someone’s life.
But the greatest influence on those who are emotionally disturbed is exerted, unmistakably, by their families. They are together often, if not every day. They know better than anyone else what those persons are thinking and feeling and doing, and more than anyone else, they care.
Unfortunately, the complications and rivalries of family life can interfere with their ability to help those among them who are emotionally disturbed. Their judgment may become clouded; through their actions, they may worsen the affected person’s condition, rather than improve it. Sometimes, indeed, they are the inadvertent cause for these emotional problems; but even then they can learn to behave differently. In a way, they too become therapists. They are the patient’s principal resource.
Psychotherapy is not so much a precise technique as it is an attitude, a way of being with a patient—and it can be learned. But unfortunately, few people are in a position to turn to a professional for supervision and instruction. Consequently, in doing "therapy," family members must struggle not only with the patient’s problems—and indeed with the patient himself or herself—but also with their own sense of inadequacy. What follows is a statement of the principles of supportive psychotherapy, as they apply to some emotional and mental disorders.
Supportive psychotherapy is the attempt by a therapist, by any practical means, to help patients deal with their emotional distress and problems in living. It includes comforting, advising, encouraging, reassuring, and mostly listening, attentively and sympathetically. The therapist provides an emotional outlet, the chance for patients to express themselves and be themselves.
In addition, the therapist may inform patients about their illness and about how to manage it and how to adjust to it. Over the course of treatment, he may have to intercede on a patient’s behalf with various authorities, including schools and social agencies, and with the patient’s family—indeed, with all of those with whom the patient may be contending.
Often, he must explain his patient’s behavior to others; at the same time, he may have to interpret the meaning of other people’s behavior to his patient. He must educate him to the unwritten but crucial rules that govern all social interaction. The therapist usually encourages his patient to expand his or her interests in the world by making friends, or by going to school or to work. He may encourage participation in sports or hobbies. To an extent, the therapist serves as a model for proper and appropriate behavior. The therapist conveys implicitly to the patient an ideology about the way that life ought to be led.
Supportive psychotherapy is a varied attempt to help patients deal with all the different problems attendant upon their emotional illness which, in turn, affects all the rest of their lives.
Insight psychotherapy is an expensive, prestigious treatment conducted by a relatively few highly trained professionals. Supportive psychotherapy, on the other hand, is conducted, in a skilled fashion or naively, by everyone who cares about the patient and is willing to care for him or her.
The methods of these psychotherapies are different. The techniques of insight therapy include the interpretation of resistances, dreams, defense mechanisms, and transference reactions to the therapist, and, nowadays, may include specific prescriptions for particular anxiety states. The process is relatively prolonged.
The supportive therapist deals more superficially, perhaps, but more immediately with the daily events of his patient’s life. He appeals to the patient’s conscious mind, rather than interpreting his unconscious. He is interested not only in what his patient tells him, which is the exclusive interest of the psychoanalyst, for example, but in whatever else he can find out from the patient’s family and friends, and from everyone else. Treatment may continue as long or longer than insight psychotherapy, at infrequent and irregular intervals, or it may be very intensive over only a short period of time.
The indications for both treatments are also somewhat different. The patient deemed suitable for insight therapy is usually intelligent, motivated, relatively intact emotionally, and relatively well off financially—that is, able to afford the cost in time and money of treatment. In addition, such an ideal patient begins treatment, ideally, already inclined to think of himself or herself in psychological terms. The patient for whom supportive therapy is recommended is likely to be poorer, less capable, and sicker. They may, perhaps, be psychotic—less able to tolerate the anxiety of looking at himself or herself objectively—but this need not be true.
In order to benefit from supportive psychotherapy, someone need not he sick to any particular degree, nor does he need to have any special kind of illness. He can be depressed, schizophrenic, sexually disturbed, or neurotic. He may be in crisis, or he may be chronically ill. He need have no special social or intellectual qualification, or impairment. He can be anyone.
Finally, the therapist himself behaves differently, depending on whether he regards himself as doing insight or supportive psychotherapy. In insight therapy, he thinks twice before saying anything, and certainly before giving advice. In order not to prejudice the patient’s remarks and attitudes, he tries to introduce as little of his own attitudes as possible. He strives toward anonymity.
When he is doing supportive therapy, on the other hand, he is active and involved. Since his patient may be too disturbed to cope effectively with day-to-day problems, the therapist will give advice. He speaks openly. He may describe his own feelings toward the patient, if his purpose is to reassure. He may speak of his own life in order to demonstrate a point. In short, he can be himself.
As is usual in psychiatry, however, these distinctions blur in practice. There are times when a patient in insight psychotherapy requires active intervention and support from the therapist—and there are times when a very sick patient can and will accept certain insights into himself. No treatment of the emotionally disturbed can be applied as a formula.
The distinction between these two idealized forms of psychotherapy is drawn here only to underline the fact that supportive therapy, at least, as it has been described here, is not exclusively in the hands of psychiatrists or psychologists but is conducted by others also. Someone who lives with, or works with, an emotionally disturbed person is cast inevitably in the role of therapist. If he actively cares for that person, he is conducting a supportive psychotherapy.
This post is drawn in part from Caring: Home Treatment for the Emotionally Disturbed.
© Fredric Neuman
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