Abstract
As psychiatrists whose primary aim in seeing patients is to initiate some change in their mental state, even if that is a restoration of a previous state, we do not cope well with any hint of helping the patient to cope with their life as it stands. Supportive therapy has long been the Cinderella of therapies, with only the scantiest of literature and no attention to it in psychiatric or psychotherapy training. Yet for most clinical psychiatrists, particularly those in the community, the patients' conditions are often chronic and are of such a nature that dynamic therapies may simply not be appropriate. All psychiatrists combine supportive elements with other modalities to form their particular treatment, but there has been little systematic attempt to establish the optimal ingredients, let alone to communicate such thoughts to clinicians.
Often clinicians see supportive therapy as merely consisting of the supportive elements of any doctor–patient interaction, and not deserving of any particular attention to developing its techniques. This has been the case despite attempts by some authors such as Holmes, Rockland and Bloch to delineate a specific treatment called supportive therapy. Pinsker clearly describes in this book a psychodynamically informed approach suitable for a broad range of clinical situations. He sees supportive therapy as conversational in technique, trying to support the patient's defences and to minimise anxiety. The aim is to reduce symptoms and to retain, restore or improve self-esteem, psychological functioning and adaptive skills. Suitable patients are not clearly defined other than those not suitable for other psychotherapeutic techniques. The book chooses a dimensional view of therapies, rather than clearly circumscribed entities, so that supportive therapy merges with dynamic therapy and counselling at each end of a continuum. I think this limits the theoretical validity of his work, but on the other hand it is a very practical approach that he is describing in this primer. There is an open admission that any description of a theory of causation is avoided, nor is there any attempt made to describe how the techniques described in the book actually ameliorate symptoms. This book derives from a manual prepared for psychiatry residents and it has all the advantages and problems that a manualised approach entails.
The book is written in a user-friendly conversational didactic tone, from the position of a mentor. A particular strength is the use of passages of therapeutic dialogue reminding me how helpful it is to show trainees how experienced clinicians handle situations. Sometimes the lack of context to these passages of dialogue, including a lack of description of these patients' clinical conditions, becomes disorienting and this limits the usefulness of the passages to increase understanding of the applicability of supportive therapy. Pinsker elaborates in each chapter the techniques of supportive therapy, including details of the applications with certain aims, for example improving self esteem or reducing anxiety.
A number of chapters are also devoted to dealing with specific aspects of the therapeutic encounter, such as enhancing the therapeutic alliance, boundary issues and the termination of therapy. These last chapters I would see as particularly beneficial since the issues are of great importance and are usually only addressed over a number of years in psychotherapy supervision. Since most trainees never have this benefit and these issues are not discussed in clinical seminars, psychiatrists could only learn from bitter experience. Pinsker clearly believes that psychotherapy can be taught in a didactic manner. Hence the choice of the term ‘primer’ rather than the traditional apprenticeship model. This is controversial, but the book at least shows how valuable it is to bring these topics up for discussion.
The book is studded with clinical gems which are set in a mass of description. They seem so blindingly obvious, yet of course they are examples of things commonly forgotten. The importance of demonstrating to the patient that he or she is kept in mind, the need not to collude by avoiding painful topics, the importance of acknowledging what is not known and so avoiding the trap of assuming the cloak of grandiosity are just a few of many examples. The major weakness of the book is the manner in which the psychiatrist is presented as the cliché of omnipotent pedagogical doctor, yet the accompanying text clearly takes a more engaging tone of a clinician being willing to sit with uncomfortable emotions. This weakness is acknowledged in the book but it makes me wonder whether the passages of dialogue are genuine or an invention. No mention is made of the psychiatrist's own feelings and the role of the counter-transference is ignored, although this perhaps reflects the American bias in therapy.
Taking the book as a whole its direct, clear and vivid way of describing the techniques of supportive therapy provides such a highly beneficial experience for the reader, that the drawbacks can be considered reasonably minor and undoubtedly reflect the inherent problems of a primer or ‘cookbook’ approach.
Although it is primarily designed for psychiatry registrars, I think the book would be of great benefit to less experienced psychiatrists and mental health professionals generally. It would also provide thought provoking reading to all clinicians who see patients for other than intensive analytic therapy, and are prepared to broaden their mind.
Supportive therapy needs to cast aside its inferiority complex and push its virtues forward, so making it worthy of study by all psychiatrists. All trainees should be familiar with the techniques set out in the book, with a richer discussion of these occurring in clinical seminars. This book is a welcome start to this endeavour and I heartily recommend it to be read as such by all.