Family Dynamics in Individual Psychotherapy: A Guide to Clinical Strategies

Family Dynamics in Individual Psychotherapy. A Guide to Clinical Strategies She has taught and supervised individual and family therapy in the doctoral.
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It may be difficult for the supportive therapist to determine where the line is between appropriate encouragement and pushing too hard or giving up on the patient too early. Like a good parent, the therapist should not settle for too little from the patient, but must also beware not to not push the patient beyond his or her capabilities so that a learning, self-esteem- enhancing activity becomes a traumatic one instead. Although this is not true for all psychologically disturbed or mentally ill individuals, the great majority of psychiatric patients will benefit from having a job, even if it is an unpaid, volunteer position.

For psychiatric patients especially, work serves other important functions besides providing an income. It structures an individual's time, provides a sense of identity, increases self-esteem, and furnishes a sense of belonging to a larger community. For patients with interpersonally barren lives, work provides a ready-made socialization experience that allows them to observe and incorporate the social skills of others and practice those skills in a real-world setting.

Thus, as a general rule the supportive therapist encourages a patient to work in whatever capacity or setting is consistent with the patient's overall level of functioning. Often at some level they recognize that they are not functioning as well as those around them. One does not successfully allay such anxieties by giving false assurances. On the other hand, it can be very helpful for patients to recognize that they are not alone. Even the narcissistic injury engendered by the realization that one is engaging in highly maladaptive behaviors can be reduced and normalized by noting that such behaviors, while currently destructive, may have been highly appropriate, perhaps even life-saving, in an earlier time or context.

Being more assertive would be helpful to you now, but had you been so as a child, it might literally have been fatal. Hopelessness in mentally ill individuals is often related to cognitive constriction, the patient's sense of having few options at his or her disposal. In that respect, removing the blinders, if you will, often greatly increases a patient's hope for the future; the patient needs to learn that there are more options available than he or she imagined. A useful approach to this problem is that of cognitive-behavioral therapy, 16 with specific discussion of negative cognitive distortions that lead to hopelessness, as well as behavioral practice to reinforce a new way of thinking.

In a similar way, the use of reframing as a psychotherapeutic tactic can combat feelings of hopelessness. One instance of the reframing technique has been described above in connection with the normalization of destructive behaviors. Likewise, a supportive therapist might reframe a year-old patient's bitter struggle with her parents as an attempt, perhaps misguided in its tactics, to obtain the entirely legitimate goal of adult autonomy: In supportive therapy the therapist may take active steps to combat hopelessness through direct environmental manipulation. Helping a patient obtain disability status, get a new apartment, keep a job, find transportation—all of these everyday specifics can be of crucial importance to the patient, and their successful negotiation leads to increased optimism about the future.

Hopelessness can also be ameliorated by elevation of the patient's self-esteem; as previously discussed, the most effective way to do this is through the development of true competence or mastery of specific skills. The here-and-now issues that should be the primary focus of supportive therapy are those concerning everyday functioning. How is the patient feeling? How is the patient getting along at work, with family, with friends? Is the patient able to pay the rent? Does he or she have difficulty finding transportation to and from work? Is group therapy beneficial? Is the patient taking his or her medication, and have there been any side effects?

It is through these everyday details that the therapist has sufficient data to judge how the patient is doing and what should be the focus of their work together. Once current mood and symptoms as well as logistical issues concerning rent, transportation, medication, and the like have been satisfactorily reviewed or addressed, the here-and-now focus should concentrate on a crucial area for most psychologically impaired patients: The more the therapist can help a patient increase his or her interpersonal awareness and reality testing as well as develop appropriate social skills, the better the patient will function in everyday existence.

Hence, social skills training, whether part of a formal program or simply integrated into the fabric of the supportive therapist's general work with the patient, is of prime importance to the patient's overall functioning and life satisfaction. The supportive therapist should work collaboratively with the patient to set an appropriate agenda for each session.

Nevertheless, it is the therapist's ultimate responsibility to ensure that the most important issues confronting the patient or therapy are addressed in a timely fashion. As a general rule, at the top of such lists are the following:. Talking about issues is often very beneficial in supportive therapy, but in the long run, discussion alone is no substitute for action. Only through the successful testing of new interpersonal behaviors or skills, the conquest of specific fears, or the mastery of feelings of inadequacy will the patient truly be convinced that he or she is capable in various domains.

It is one thing to talk to a year-old boy about his feelings of failure; it is quite another to teach him to hit a home run when playing baseball with his friends; it is the latter experience that is most likely to serve as an antidote to his feelings of inadequacy. It is also helpful to have the patient set concrete, achievable behavioral goals. The setting of specific, concrete, achievable behavioral goals serves another important function: Often they must first practice and master part-behaviors or components of the overall skill.

Subsequently, these component behaviors are integrated with one another in increasingly sophisticated ways that ultimately lead to competence in the application of the entire, complex skill. Returning to a previous example, a patient needs to get a job in order to support herself. The supportive therapist may work sequentially with the patient on each of the steps involved in the process of obtaining a job: By setting specific, concrete behavioral goals, it is possible to break large accomplishments into smaller ones, transform seemingly overwhelming tasks into manageable lesser tasks, and set the patient up for success rather than failure.

The supportive therapist, like a good parent, should assess the patient's current psychological state and capacities, the overall context, and the specific task under consideration, pondering if, when, and how the patient should venture forth into a new or difficult experience. Thereafter, the therapist should work with the patient to devise a specific plan of action, using whatever techniques may be most beneficial in dealing with a particular issue or problem for this particular patient.

With the typical supportive therapy patient, behavioral approaches—behavioral rehearsal, role playing, relaxation, graded exposure, visualization and imagery, and so forth—are often the most useful in helping the patient to reach his or her goals. Many of these techniques are enumerated and detailed by J. Beck 16 and by Linehan. Beck 16 provides sensible guidelines in this regard, stressing the importance of working collaboratively with the patient to set homework; starting assignments in the office; reviewing homework at the next session; anticipating and troubleshooting potential difficulties; and, more generally, attending to activity monitoring and scheduling.


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Here, again, the supportive therapist serves as a cheerleader for the patient's efforts, even if such efforts are initially unsuccessful or even disastrous. Education is invariably a large and important part of the supportive therapist's work. Using understandable, nontechnical language and employing sensitivity to what the patient can and cannot tolerate hearing at a given time, the therapist tries to help the patient learn about his or her illness e. The illness's symptoms, course, and prognosis are discussed.

Special attention should be directed toward precipitants of decompensation e. Armed with knowledge of precipitants and warning symptoms specific for a particular illness in his or her particular case, the patient can take steps to prevent, or at least ameliorate, psychological breakdown. If the patient is prescribed psychotropic medications, he or she should be educated with respect to indications for the pharmacologic intervention, expected time course and benefits, and risks and side effects.

Throughout the continuing process of such education, it is important that the supportive therapist preserve hope in the patient, balancing the reality of the patient's circumstances with appropriate optimism for the future. Especially with the more severely or chronically mentally ill, there may be great benefit to similarly educating the patient's family, significant others, key friends, employer, or various social agencies. At the same time, however, the patient's wishes, autonomy, and confidentiality must be respected.

Except in cases of emergency e. A second educational role of the supportive therapist has already been mentioned above. That is, the therapist may also educate the patient with respect to reality testing, modulating affect, controlling impulses, making connections, developing social skills, obtaining a job, preparing a budget, using public transportation, applying for social security disability, and any other specific tasks or functions that the patient is unable to enact without help.

In each of the above instances, knowledge empowers the patient, leading to actual competency and elevated self-esteem. Some of the differences between supportive therapy and psychodynamic, psychoanalytic, or insight-oriented psychotherapies 8 have already been highlighted. A final consideration in this regard relates to the therapist's willingness to manipulate the environment around the patient. The supportive therapist, unlike the typical psychoanalyst, may intervene with other persons or agencies to help the patient, again with due regard for the patient's independence and privacy.

Hence, the supportive therapist may attempt to maximize family support by working with key family members. The therapist may enlist the aid of various social service agencies, speak with an employer to explain the patient's condition, communicate with the court system, perhaps even accompany the patient to the Social Security office if necessary. The supportive therapist's role is once more akin to that of a good parent.

He or she provides the help that is needed i. Although it is the most common psychotherapeutic treatment paradigm for mentally ill patients, supportive therapy receives relatively little time in the typical mental health professional training curriculum. This, in conjunction with the employment of diverse techniques from different psychotherapy paradigms, has left many mental health professionals confused as to the fundamental nature and process of supportive therapy. The basic strategies that provide the foundation for effective supportive therapy have been described so that the supportive therapist can focus his or her interventions to maximize benefit to the patient.

Amy is a year-old college senior who presents to the Student Health Service Counseling Center on her own initiative with a 2-month history of depressive symptoms accompanied by faltering grades and intermittent alcohol abuse. There is no history of psychiatric hospitalization, suicide gesture or attempt, or previous contact with a mental health professional other than the school counselor.

Early in her junior year at college, Amy's primary care physician had prescribed fluoxetine 20 mg daily because of dysphoria, impaired sleep and concentration, and decreased appetite with a 5-pound weight loss over the preceding 3 months. Four months later, however, Amy discontinued the medication on her own, feeling that it had provided no significant relief. Over the course of the last semester, however, her grades have fallen markedly. Even more worrisome for Amy herself has been the new onset of excessive drinking, a behavior very unlike Amy.

Amy has a number of pressing concerns. As the end of her senior year in college approaches, she is still unsure about a future career. Her father wants her to enter law school, but she is more inclined to become a writer, an occupation that he views as frivolous and risky. A second concern for Amy is that she has become increasingly estranged from her two female roommates, feeling over the past semester that she has less and less in common with them.


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He is a bright but rigid and demanding premedical student who is very critical of others. Amy is the youngest of three sisters. Her father, an attorney at law, is a hard-driving, perfectionistic, and demanding senior partner of a prestigious law firm in a large city. Amy's father has high expectations of everyone in the family; he requires each family member to be intelligent, attractive, physically fit, and successful. In contrast, Amy's mother, formerly a nurse but now a full-time homemaker, is much less assertive than Amy's father.

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Indeed, she too seems intimidated by her husband's demands for excellence. All of the women in the family—mother and daughters—have felt his pressure to remain trim and attractive, attain top grades, and be occupationally successful. Amy's eldest sister has completed law school and is now clerking for a prominent federal judge. The middle sister is in her final year of law school, planning to specialize in international finance. There is no history of mental illness within the family. Amy has no history of significant medical illnesses or surgery.

Her only regular medication consists of a multivitamin tablet daily. Amy has briefly experimented with marijuana and cocaine, but currently she acknowledges only the use of alcohol. Although abstaining from alcohol consumption during the week, on a typical weekend evening over the past 2 months Amy has consumed several cans of beer followed by three to five mixed drinks.

These drinking binges typically occur in a local bar with acquaintances from class. These concerns have intensified during Amy's senior year in college as she is forced to confront the question of what she will do after graduation. In spite of her many strengths intelligence, humor, athletic prowess, and physical beauty , Amy feels fundamentally unlovable, unattractive, and incompetent.

Amy is well aware that her father is greatly disappointed in her insofar as she is unwilling or unable to follow in the footsteps of her older sisters, who are both straight-A students well on the path to becoming powerful and successful lawyers as well as beautiful women.

In this respect Amy identifies with her mother, a passive and depressed woman who analogously feels that she can never do, or be, enough for her husband. Not only does Amy share with her mother a deep-seated sense of unworthiness, but also in her relationships with men Amy demonstrates her mother's passivity, masochism, and fears of criticism and rejection. Like her mother, Amy is reluctant to become emotionally intimate with a man, believing that such a relationship ultimately places her in a vulnerable position from which she is likely to experience more pain and disappointment than gratification.

In contrast, Amy's recent estrangement from her female roommates and her generally limited relationships with other women her age reflect long-standing conscious and unconscious competition with her older sisters. Amy views other women, especially aggressive and successful women, as competitors in relation to whom she always appears to be inferior.

Isolation of affect and turning anger against the self, both modeled by Amy's mother, serve to contain Amy's feelings and prevent angry retaliation on the part of her aggressive father; the latter defense, however, results in feelings of guilt, shame, and depression. Through the defense mechanism of displacement, Amy is able to channel her aggressive and competitive impulses into athletic activities that avoid direct conflict with her family.

Intellectualization serves a similar purpose, allowing Amy to compete with her father and sisters in the cognitive domain although in areas other than law , which they most highly value. The process of intellectualization also reinforces the containment of feelings that Amy is fearful of releasing.

The recent onset of excessive drinking and perhaps falling grades may reflect Amy's underlying depression, but they also serve to act out some of her unconscious conflicts. Amy's increasing depression and recent acting out have been precipitated by the pressure of her impending graduation from college, forcing her to confront issues about herself and her family that she has tried to suppress. Although unconsciously Amy symbolically seeks her father's approval and acceptance within her relationship with her boyfriend, instead she experiences criticism and rejection that recapitulate her relationship with her father.

In addition to her intelligence, humor, athletic prowess, and physical attractiveness, Amy has other strengths. Her interpersonal anxieties notwithstanding, Amy is socially appropriate and adept and has good empathy for others. In general she is an unselfish and kind person. In many areas of functioning she has demonstrated creativity, persistence, and courage.

Her current lack of impulse control with respect to alcohol consumption is the exception rather than the norm. Finally, although currently feeling overwhelmed and confused, Amy generally possesses good introspective capacities, including the ability to view herself and her behavior objectively. Amy easily falls within the inclusion criteria for a variety of psychotherapeutic approaches, including, at the very least, supportive psychotherapy and psychodynamic psychotherapy.

The therapist's decision to employ supportive therapy as the primary approach in Amy's treatment reflects his assessment of the realities of patient choice, resource limitations, and college life. Although Amy could certainly benefit from psychodynamic psychotherapy, she is, in fact, a soon-to-be-graduating senior in college who will likely move to a different area of the country. Even more immediately, however, Amy, like many patients, seeks rapid amelioration of her symptoms and concrete guidance in moving forward in her life. As noted earlier, and consistent with changing patient expectations, needs, and resources, Hellerstein et al.

For Amy, the supportive therapist as a good parent 2 requires appropriate containment of her self-destructive behavior balanced with validation of her strengths, dreams, and goals.

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The therapist's objective is not to impose a particular occupational choice or life plan on Amy, but rather to help her make her own choices as well as to find, and accept, herself. The focus of supportive work with Amy will be less on the psychodynamics of her family and peer relationships than on the present the here and now 13 and the future: Such therapeutic work may involve exploration of the past in order to understand Amy's present situation, thoughts, feelings, and behavior; the goal, however, is not to recapitulate the past in the present e.

The most immediate goals for Amy's therapy are to ameliorate her depressive symptoms, contain or limit her self-destructive acting out through the abuse of alcohol, and prevent serious damage to her future career by academic failure in her senior year at college. Because Amy already knows full well, and feels guilty about, the destructive nature of her behavior her current conduct notwithstanding, she possesses a strong sense of right and wrong , and has demonstrated good impulse control throughout most of her life, it is likely that the supportive therapist will not need to aggressively set limits i.

Indeed, the very fact of addressing her problems with a mental health professional may be sufficient to allow Amy to regain her usual appropriate control of her behavior. Amy's depression will require supportive therapeutic techniques that focus on both short-term and long-term issues, perhaps in conjunction with antidepressant medication if her symptoms are sufficiently severe.

Amy is struggling with the definition and consolidation of her identity as an individual, an identity distinct from that dictated by her father. In this struggle Amy is neither alone nor abnormal, for a key developmental task of late adolescence and early adulthood is to forge such a new sense of self. Similarly, it is not uncommon for this healthy consolidation of identity to result in family conflict, especially in families that implicitly or explicitly demand that children follow their parents' dictates and aspirations rather than their own. Amy may benefit from a reframing 12 of her difficulties with her father as a strength, rather than a failure, on her part—a sign of her struggle for autonomy and an authentic self.

Indeed, she might even be portrayed as more independent and courageous than her more highly acclaimed sisters for daring to go her own way. Ultimately, you'll get through this just like other people your age. To this end, the therapist may disclose 8 some of his own difficulties in defining himself and breaking away from his family of origin i. Although Amy is currently feeling overwhelmed, her life history suggests that she is generally capable of functioning at a mature psychological level.

Thus, the supportive therapist's lending of psychic structure 6 is likely to be temporary and situation-based. Reality testing 6, 8 might focus on the recognition and acknowledgment of Amy's real strengths e. The therapist would do well to encourage activity. By breaking down the seemingly overwhelming task of deciding on a career and finding a job into smaller, definable, stepwise goals, the therapist sets her up for success rather than failure 11 and, concomitantly, ameliorates hopelessness.

Amy would also benefit from borrowing the supportive therapist's superego, 6 but not because she lacks sufficient feelings of guilt or shame regarding her recent alcohol-related acting out and academic decline. Quite to the contrary, the therapist might want to help Amy stop castigating herself for not being exactly what her father wants her to be, to learn to accept herself for who she is and what she wants to do in life.

Thus, it is a less harsh, more forgiving superego that the therapist might provide for Amy's use and internalization. As previously noted, control of Amy's acting out requires more ego than superego; she already feels guilty and ashamed of her behavior, but she does not understand why it is happening and how to stop it. With sufficient clarification and support, Amy will likely regain control over her self-destructive actions.

The supportive therapist is required less to foster competency 11 in Amy than to help her recognize and accept the many competencies already in her possession, even if they are not the same skills valued by her father. In this respect a cognitive therapeutic approach may be helpful in allowing Amy to have a more balanced perspective on her strengths and weaknesses.

Nevertheless, in comparison to her other talents, Amy is considerably less capable and competent in her interpersonal relationships with men and, more recently, with women her age. A combination of an exploratory approach e. Amy needs only a modicum of education 15 about mental illness per se e. The supportive therapist may help Amy to make connections 10 between her feelings and both her depressive symptoms and her acting out.

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Making these connections can help with maximization of her adaptive coping mechanisms 7 e. Thus, for example, as Amy becomes more aware of her anger at her father, the therapist may work with her to replace destructive coping strategies e. Similarly, the therapist might elect to use another of Amy's strengths, her wordsmithing abilities as a future writer, to help her identify, acknowledge, and appropriately express her feelings 9 about her family.

Amy's therapist needs to be aware of and to manage transference difficulties 4 that may impinge on the therapeutic relationship. In particular, Amy may react to a male therapist with feelings transferred from her relationship with her father, misinterpreting the therapist's comments as dominating, critical, and rejecting. She may then respond to these feelings by becoming passive or defensive or by increased acting out. In contrast, Amy might view a female therapist, especially one closer to her age than to her mother's, as a competitive sibling to be regarded coldly, suspiciously, and enviously.

In either case, the supportive therapist should foster the therapeutic alliance 3 by attempting to ally with Amy's healthy ego—those parts of her that are appropriately concerned with her falling grades, alcohol abuse, career dilemma, and interpersonal difficulties. The supportive therapist would need to enact relatively few environmental manipulations 16 on Amy's behalf. For example, because she is 22 years of age, many therapists would be reluctant to speak directly with her family, feeling that Amy's age-appropriate developmental task is to increase her autonomy and learn to negotiate issues with her family on an adult-to-adult basis.

On the other hand, a supportive therapist might help Amy to obtain the application materials for the GREs, make specific contacts for a job after graduation, or refer her to an appropriate group therapy experience with similar high-functioning individuals.

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National Center for Biotechnology Information , U. J Psychother Pract Res. Received October 26, ; revised April 28, ; accepted May 24, Send correspondence to Dr. Misch at the above address; e-mail: This article has been cited by other articles in PMC. Abstract Supportive therapy is the psychotherapeutic approach employed with the majority of mentally ill individuals.

Formulate the Case The mere mention of the word formulation often unsettles psychotherapists, neophytes and veterans alike, calling forth fantasies of having to construct a lengthy and exhaustively detailed psychoanalytic understanding of every nuance of the patient's mental life, beginning from birth or perhaps even prenatally and continuing to the present time.

Be a Good Parent Perhaps the single most helpful concept in guiding the therapeutic interventions of the supportive therapist is to view the therapist—patient relationship in analogy to the parent—child relationship. Foster and Protect the Therapeutic Alliance Although there is some disagreement, in general the failure to foster and maintain a good working or therapeutic alliance 43 between patient and therapist is a predictor of poor psychotherapy outcome. Manage the Transference Patients invariably have feelings about their therapists.

Hold and Contain the Patient The concepts of holding and containing refer to a therapist's attempts to be a good parent by providing empathy, understanding, and verbal soothing; modulating affect; restricting self-defeating impulsivity or acting out; and generally setting appropriate limits. Maximize Adaptive Coping Mechanisms In all psychotherapy, including supportive therapy, an important goal is to increase a patient's coping skills and use of adaptive defense mechanisms. Provide a Role Model for Identification A corollary of the therapist's strategy of lending psychic structure to the patient might appear obvious, but it is worth underscoring because of its importance in supportive therapy: Decrease Alexithymia The concept of alexithymia has generated considerable controversy.

Make Connections It is easy to underestimate the difficulty that psychologically impaired individuals may have in making the connections that otherwise healthy people make in everyday life. Raise Self-Esteem Foster Competency: Normalize Thoughts, Feelings, and Behaviors: Ameliorate Hopelessness Hopelessness in mentally ill individuals is often related to cognitive constriction, the patient's sense of having few options at his or her disposal.

As a general rule, at the top of such lists are the following: Threats to physical safety of the patient or others, such as suicidal or homicidal thoughts or behaviors. Therapy-interfering behaviors, such as requests to decrease session frequency or to terminate the therapy, plans to leave the geographic area, failure to pay for therapy, destruction of office property, boundary intrusions involving the therapist.

Future-foreclosing events or plans, 54 such as precipitously leaving a job or moving out of one's house without alternative living arrangements. Treatment noncompliance, such as failure to take necessary medications or to see an auxiliary therapist or psychiatrist. Educate the Patient and Family Education is invariably a large and important part of the supportive therapist's work.

Manipulate the Environment Some of the differences between supportive therapy and psychodynamic, psychoanalytic, or insight-oriented psychotherapies 8 have already been highlighted. AMY Amy is a year-old college senior who presents to the Student Health Service Counseling Center on her own initiative with a 2-month history of depressive symptoms accompanied by faltering grades and intermittent alcohol abuse.

Dynamic Psychiatry in Theory and Practice. Philadelphia, Lea and Febiger, The Practice of Supportive Psychotherapy. New York, Basic Books, Supportive Therapy for Borderline Patients: New York, Guilford, A review of supportive psychotherapy, — Hosp Community Psychiatry ; Clinical Manual of Supportive Psychotherapy, 1st edition. A Primer of Supportive Psychotherapy. Hillsdale, NJ, Analytic Press, Principles of supportive psychotherapy. Am J Psychother ; J Am Psychoanal Assoc ; Freyberger H, Freyberger HJ: Psychother Psychosom ; Supportive therapy as the treatment model of choice.

J Psychother Pract Res ; 3: Cognitive Therapy of Depression. Cognitive Therapy of Anxiety and Phobic Disorders. Philadelphia, Center for Cognitive Therapy, Cognitive Therapy of Personality Disorders. Cognitive Therapy of Substance Abuse. Interpersonal Psychotherapy of Depression. Journal of Marital and Family Therapy 13 1 , , Journal of Psychotherapy Integration 2 3 , , Journal of contemporary psychotherapy 10 2 , , Journal of Strategic and Systemic Therapies 9 1 , , Working Systemically with Families: Journal of Marital and Family Therapy 22, , Articles 1—18 Show more.

Family dynamics in individual psychotherapy: The family psyche over three generations: An integrative approach to working with troubled children and their families. The language of becoming: Helping children change how they think about themselves EF Wachtel Family process 40 4 , , The dilemmas of an individual therapist EF Wachtel Journal of contemporary psychotherapy 10 2 , , Guilford Press , We Love Each Other, But The heart of couple therapy: