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Bedside PsychotherapyRyan Peterson, MD

Sharvari Shivanekar, MD3rd Annual UPMC Psychosomatic Medicine Conference

Saturday, April 21, 2018

Bedside Psychotherapy

Introduction Learning Objectives Brief Review of Literature 3-Step Supportive Psychotherapy Manual Techniques in Supportive Psychotherapy Clinical Vignette Discussion and Role Play

Introduction

Definition of supportive psychotherapy Treatment characterized by the use of direct measures to

ameliorate symptoms and to maintain, restore, or improve self-esteem, adaptive skills, and psychological function.

Rationale for use in variety of clinical settings beyond outpatient clinic

Supervisors and Trainees alike benefit from structured supervision and didactics

Learning Objectives

By the completion of this session, participants should be able to: 1. Describe how to tailor supportive therapy to inpatient CL

settings.2. Gather tools for effective use of supervision time with

trainees3. Apply principles of supportive therapy to integrative clinic

settings.

Brief Review of the literature Effect of Supportive Psychotherapy on Mental Health Status and Quality of Life of Female Cancer

Patients Receiving Chemotherapy for Recurrent Disease. Mukherjee, A. et al (2017) 4 sessions of supportive psychotherapy in 40 patients with outcomes measuring pre- and post-

psychotherapy evaluation of anxiety, depression and overall quality of life Significant reduction in anxiety, depression; improvement in QOL in physical & psychological

health, social relationships, environment Conclusion: Supportive therapy should be encouraged to promote positive mental health and

obtain full benefit of physical treatment

Brief Review of the Literature Teaching Supportive Psychotherapy to Psychiatric Residents. Carolyn Douglas, MD 2008 Few publications on guidelines and consensus of what residents should be taught Identify: What needs support; Provide a holding environment, Be Yourself, Do Just Enough need for faculty training in psychotherapy supervision and suggested developing supervision

competencies to ensure that faculty are prepared to provide adequate teaching and professional development for their trainees

Some authors have suggested that training residents to adhere consistently to empirically supported techniques leads them to oversimplify the complexity of real-world clinical problems, interferes with their attunement to the individual persons needs, and curtails the flexibility and spontaneity that characterize truly competent psychotherapists

As supportive psychotherapy teachers, we should remain ambitious about what our trainees can learn but realistic that we are all mostly self-taught as therapists

Brief review of the literature: Thinking Outside of Outpatient: Underutilized Settings for Psychotherapy Education: Cabaniss et

al Academic Psychiatry 2016 177 psychiatry residency directors surveyed about therapy teaching 95% indicated that therapy is learning objective for outpatient clinics

Brief review of the literature:

Supportive Techniques: Are They Found in Different Therapies? Barber et al Journal of Psychotherapy Practice 2001

Woody et al.41 study that examined efficacy of individual drug counseling (IDC), supportive- expressive psychotherapy (SE) and cognitive behavioral psychotherapy (CBT) 44 opiate dependent veterans randomly assigned to therapist Audiotapes reviewed by independent judges Findings:

IDC, SE and CBT therapists used interventions consistent with their manuals Supportive techniques were rated almost identically across all therapies

Conclusions: Supportive techniques are often used in different types of therapies and counseling

Brief review of the literature: Interpersonal Change in Brief Supportive Psychotherapy. Rosenthal et al Journal of Psychotherapy

Practice and Research 1999 Traditionally seen as the treatment for those not suitable for expressive therapy selection bias in that more difficult patients are routinely shunted to supportive psychotherapy and

the better candidates for therapy are selected for expressive treatments notion that supportive psychotherapy is not indicated for what Murphy called YAVIE (young,

attractive, verbal, intelligent, and educated) patients assigning very sick and very difficult patients, the image of supportive therapy as a low-potency

intervention is perpetuated Beth Israel Brief Psychotherapy Program, the authors studied the efficacy of supportive

psychotherapy in personality change Results from IPP ( Inventory of Personal Problems) after 40 sessions over 6 months showed lasting

positive changes in interpersonal functioning

3 Step Supportive Psychotherapy Manual

Manual developed by Deborah Cabaniss, MD at Columbia University

Manual is available for training programs to use with residents Ego supportive psychotherapy aims to support a weakened ego

by strengthening defense mechanisms Does not focus on unconscious conflicts Aims at shoring up defenses to increase adaptiveness of

patients coping mechanisms Deborah Cabaniss, 3-Step Supportive Psychotherapy Manual, copyright 2015

Supportive psychotherapy is appropriate for those patients who show evidence of ego weakness: predominant use of primitive defense mechanisms impaired reality testing limited impulse control cognitive impairment grossly impaired relationships with others Inability to tolerate strong affects

Deborah Cabaniss, 3-Step Supportive Psychotherapy Manual, copyright 2015

Much of what we as mental health professionals do on inpatient units, the Consult Liaison Service and the ER is psychotherapy.

Most of us are engaged in this treatment with patients without realizing it!

The 3 Step Manual is designed to use supportive psychotherapy effectively in inpatient units, CL and ER settings.


What is needed for psychotherapy?

A patient A mental health provider Talking A frame ( basic parameters such as a place to meet, length of

time and fees) A goal: improving patients emotional and mental health


Step 1: Evaluate the patient In addition to major psychiatric problems, assess ego function

and difficulties in coping- Defenses/coping strategies- Impulse control and judgement- Self esteem regulation- Relationships with others- Affect and anxiety tolerance - Reality testing


The therapy begins WHILE you are getting information from patient in the initial assessment.


Ask these essential questions: Who are the most important people in your life and how are

you getting along with them? Tell me about a time when you handled a crisis well. What are the things you are most proud of in your life? How can I most help you now?


Step 2: Set Goals Patients in inpatient/CL/ER settings are in crisis Any of these six goals may apply, pick 1 or 2:

- Understanding their own feelings, having theirs understood by others- Making sense of what brought them to current crisis- Maintaining self esteem during crisis- Mobilizing adaptive coping skills to deal with current crisis- Effectively relating to others during crisis- Planning for short term future


Step 3: Make a Plan Making an Alliance

Setting the Frame & Establishing Boundaries

Empathic Listening


Alliance Building

Be a real person Sit down Make eye contact (Dont take notes) Show the person that you are interested, express

understanding, show empathy


Setting the Frame & Establishing Boundaries

Where you will meet When you will meet How long your meetings will be How many total meetings you will have

Frame varies based on setting and location Consider the needs of the patient and the logistics of the

serviceDeborah Cabaniss, 3-Step Supportive Psychotherapy Manual, copyright 2015

Empathic Listening

Listening goes a long way Use validating statements Reflect Repeat and re-phrase so the patient knows

you are understanding

Make a Plan: Supervision Much of the initial steps for making a plan will be accomplished

during the initial consult Take a few minutes during supervision to discuss strategies

Making an alliance What kind of frame How to listen empathically


Put the Plan into Action At the next visit discuss

Goalsshare what you are considering with the patient and identify what s/he would like to work on

Frameagree up on the duration and frequency of meetings


Bedside Psychotherapy Introduction Learning Objectives Brief Review of Literature 3-Step Supportive Psychotherapy Manual Techniques in Supportive Psychotherapy Clinical Vignette Discussion and Role Play

Supportive Therapy Techniques

Contextual techniques Tactical techniques Skills building

Contextual Techniques

Adopting a conversational style Maintaining the frame of treatment Being like a good parent Focusing on real relationships

Tactical Techniques Alliance building

- Expression of interest, empathy- Expressing understanding- Repairing misalliance- Self disclosure ( judicious)

Esteem Building- Praise - Reassurance- Encouragement

Enhancement of ego functioning- Anxiety reducing interventions: Limit setting, modulating affect, naming the problem,

reframing, minimization- Awareness expanding interventions: Clarification, humor, confrontation, interpretation

Skills Building Giving advice Teaching Modeling adaptive behavior Providing anticipatory guidance Redirecting Promoting autonomy

Techniques in Supportive Psychotherapy

Encourage patient to talk about feelings Help the patient tell their story Identify patient strengths and ways they have handled past crises

Both positively and negatively handled situations Highlight Strengths and Past Accomplishments Learn about key relationships

Both at home and in the hospital Can act out future interactions

Talk about next stepsAnticipatory guidance for after discharge

Supportive Psychotherapy Supervision on C/L Psychiatry Rotation: Practicalities

1 hour didactic Techniques in Supportive Psychotherapy Includes examples and brief vignettes with discussion

1 hour supervision with trainee (PGY2) A: 10-15 minutes to discuss patient ego function, choose 1 to 2 goals,

strategies for frame and alliance using 3-step Supportive Psychotherapy Manual

B: 15-30 minutes supportive psychotherapy session directly observed by the supervisor

C: 10-15 minutes debriefing and preparation for the next session 1 hour group supervision and case discussion

Common Pitfalls in Supportive Therapy Supervision

Trying to do too much

Missing salient affective or verbal cues

Misalignment of goals

Asking too many questionsdiverting from a conversational style

Bedside Psychotherapy Introduction Learning Objectives Brief Review of Literature 3-Step Supportive Psychotherapy Manual Techniques in Supportive Psychotherapy Clinical Vignette Discussion and Role Play

Clinical Vignette: 34 YO man admitted to the transplant service with acute abdominal pain diagnosed as acute pancreatitis a successful renal transplant 10 years ago He developed a marijuana use disorder after renal transplant but was able to stop use with the help of a

substance use program He then required a pancreas transplant one year ago since which time he has experiences multiple

complications including repeated infections and recurrent pancreatitis transplant team requests a psychiatric consult after Johns nurse notes that he has been crying alone in

his room since the admission but has maintained that everything is fine. In the initial evaluation, John expresses gratitude for resident sitting next to his bed and really listening Initially reluctant to discuss source of his distress, John eventually reveals that he has been crying

because he is heartbroken His wife of 12 years, Ellen, who was a strong support through the first transplant, asked John for a

divorce about two months ago

Clinical Vignette:

John states that the second transplant and its complications has created so much strain in their relationship that he is not surprised by Ellens decision but does not feel capable of coping with the separation.

John feels like he is already burdening the resident, the transplant team and his friends and family with his medical problems and thus does not wish to add to the burden by discussing his marital problem. He also feels that Ellen cannot be blamed for leaving him.

John used to work as a chef in a French restaurant but lost his job due to his prolonged absence and now lives with his parents, who he finds very supportive.

He has never seen a psychiatrist or therapist, but had a few sessions of couples counseling with Ellen before the transplant which he had found helpful.

Discussion Questions about how we implement supportive psychotherapy teaching,

supervision into clinical practice?

How are others approaching psychotherapy and supervision in their clinical setting?

How might you incorporate these techniques into your clinical settings?

What other ideas would make you feel more comfortable/confident as a therapist or supervisor?

Teaching Resources 3-Step Supportive Psychotherapy Manual for CL/ER/Inpatient Rotations

Deborah Cabannis MD et al 2015 Techniques in Individual Supportive Psychotherapy from Textbook of

Psychotherapeutic Treatments Richard N Rosenthal MD

Basic Strategies of Dynamic Supportive Therapy Donald Misch MD

ACGME Milestones: Supportive therapy includes the capacity to generate a case formulation, to

demonstrate techniques of intervention, and to strengthen the patients adaptive defenses, resilience, and social supports.

References Douglas, C. (2008). Teaching Supportive Psychotherapy to

Psychiatric Residents. The American Journal of Psychiatry. Volume 165 (Issue 4), pp 445-452.

Blumenshine, P. et al (2017). Thinking Outside of Outpatient: Underutilized Settings for Psychotherapy Education. Academic Psychiatry. Volume 41 (Issue 1), pp 16-19.

Mukherjee, A. et al (2017). Effect of Supportive Psychotherapy on Mental Health Status and Quality of Life of Female Cancer Patients Receiving Chemotherapy for Recurrent Disease. Indian Journal of Palliative Care. Volume 23 (Issue 4), pp 399-402.

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Bedside PsychotherapyBedside Psychotherapy IntroductionBedside Psychotherapy Learning ObjectivesBedside Psychotherapy Brief Review of the literatureBrief Review of the LiteratureBrief review of the literature:Brief review of the literature:Brief review of the literature:Bedside Psychotherapy 3 Step Supportive Psychotherapy ManualSlide Number 14Slide Number 15What is needed for psychotherapy?Step 1: Evaluate the patientSlide Number 18Ask these essential questions:Step 2: Set GoalsStep 3: Make a PlanAlliance BuildingSetting the Frame & Establishing BoundariesEmpathic ListeningMake a Plan: SupervisionPut the Plan into ActionBedside Psychotherapy Supportive Therapy TechniquesContextual TechniquesTactical TechniquesSkills BuildingTechniques in Supportive PsychotherapySupportive Psychotherapy Supervision on C/L Psychiatry Rotation: PracticalitiesCommon Pitfalls in Supportive Therapy SupervisionBedside Psychotherapy Clinical Vignette: Clinical Vignette: DiscussionTeaching ResourcesReferencesSlide Number 41Slide Number 42

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How to use this PowerPoint template - antrios.wpic.pitt.eduantrios.wpic.pitt.edu/files/file/Peterson-BedsidePsychotherapyV4... · • Talk about next steps—Anticipatory guidance