Supportive Psychotherapy 101

An article in Psychiatric News on June 15 by Arnold Winston [his book] offers a quick review about the elements of supportive psychotherapy and why it has become the most widely used form of psychotherapy.

Definition of supportive psychotherapy: designed to reduce symptoms, improve self-esteem, and maximize adaptive capacities.

TECHNIQUES

• alliance building (expressions of interest, empathy, conversational style)
• esteem building (reassurance, normalizing, encouragement)
• skills building (advice, teaching, anticipatory guidance)
• reducing and preventing anxiety (normalizing, reframing, rationalizing)
• expanding awareness (clarification, confrontation, interpretation)
• strengthening defenses (as opposed to challenging them)
• other cognitive-behavioral (identification and examination of automatic thoughts, relaxation exercises, assertiveness training, exposure treatment)

QUALITIES

• supportive
• empathic
• nonthreatening

THERAPEUTIC ALLIANCE

• affectionate bond between patient and therapist
• agreement on the task and goals of the therapy
• patient's capacity to perform therapeutic work
• therapist's empathic relatedness and involvement

No Place To Go

There is a fantastic article up on the New York Times website, coming out in print this weekend in the NYT Magazine, called When My Crazy Father Actually Lost His Mind, by Janeen Interlandi.  The author tells the chaotic story of how her family tried to get help for her 69 year old father who was ill with a manic episode.  In it, he bounces from hospital to jail to ER, to homelessness, over and over. She talks about the catch-22's with the legal/psychiatric system with a father who is dangerous enough for a restraining order to keep him from his family, but not dangerous enough for civil commitment, and she talks about stories of others families where awful things have happened.  Her love for her father comes through, mixed in with her frustration that there is no place or mechanism to help such people.  Ah, but the story has a happy ending.  It reminded me a lot of Pete Earley's book Crazy: A Father's Search Through America's Mental Health Madness.


Interlandi writes:


And so for weeks, we had been locked in a game of chicken: waiting for my father to do something clearly dangerous; praying like hell that it would not be his suicide or accidental death or the death of someone else. In the meantime, my mother had all but stopped sleeping and had started hiding the car keys and the checkbook. She would tiptoe around their one-bedroom apartment at night, waiting for him to doze off, then call my sister or me to unload her despair in a flurry of whispers. 

Oh, I can't begin to  do this article justice in a blog post, you'll just have to read it.

The High Cost of (No) SuperMax

Recently NPR featured a story on All Things Considered about the state of Illinois closing its SuperMax prison in Tamms. The story talked about the fact that the prison cost twice as much as other prisons to run, in spite of the fact it housed only 200 prisoners. It mentioned human rights organizations that felt control unit prisons or "SuperMax" facilities were environments that inflicted cruel and unusual punishment. The story implied that longterm solitary confinement caused mental illness and that such prisons did nothing to improve safety in the correctional system.


Wow, I wonder which correctional system they were working in.


I work in a system that at one time had one of the highest internal homicide rates in the country. (Internal homicide refers to murders committed within prison, by prisoners.) I have worked in a control unit prison, and I can tell you that the average citizen can't comprehend the level of depravity shown by some of the inmates there. I'm talking about prisoners who have long histories of violence, dating back to elementary school years. When the New York Times ran a story recently about nine-year-old psychopaths, the first people I thought of were some of my SuperMax inmates.


In my correctional system you have to work to end up in a control unit prison. Beds are few, they are expensive, and they aren't given out like candy. SuperMax inmates are people who are repetitively assaultive to their peers or staff, who repeatedly destroy property or set fires, or who actually kill someone at a lower level of security. Single incidents short of murder are rarely enough to warrant a high security transfer.


Even housing in a control unit prison is not a guarantee of safety: control unit prisoners have continued to run gangs and even to kill in spite of that high security environment.


And now advocacy groups want these facilities closed, and these prisoners turned loose upon their peers in lower security settings. Frankly, if I were a parent of a medium security inmate I would be very concerned about that.


Then there is the allegation of mental deterioration. I've ranted...er, written...about this topic a few times before here on Shrink Rap and also on Clinical Psychiatry News. Briefly, what advocacy groups don't mention---and their expert consultants also sometimes overlook---is that control unit prisoners are a very disturbed group to begin with, even prior to transfer to the facility. They have severe personality disorders which press the limits of our psychiatric diagnostic criteria. They have maladaptive learned behaviors that seem bizarre to the outsider but serve a clear, logical purpose to those familiar with the correctional environment. In spite of this, recent research has shown that solitary confinement can actually improve rather than worsen this psychological disturbance.


Let's assume for a minute that longterm solitary confinement did have detrimental effects for most prisoners, just for the sake of argument. Most systems do have psychological services in place to address this. Prisoners eligible for longterm solitary can be screened for pre-existing psychiatric conditions, and those conditions can be treated with medication, counselling and behavior management even in a control unit environment. Most SuperMax facilities have policies that require regular rounds on segregation inmates, and psychological services are available.


Abolition of an entire facility is an extreme response to a theoretical problem. The violence posed by control unit inmates, unfortunately, is not theoretical.

Groupons for Mental Health Care?

So usually they want to feed me dinner, wax my bikini line, or teach me to para-sail.  Today, a Groupon caught my attention: there is one to provide mental health care service to military personnel and their family members-- a contribution to Groupon is met with a matching gift from an anonymous donor.


Somehow, it feels rather sad that our nation can afford so many things, but mental health care for our soldiers gets relegated to Groupon ads.  Still, I contributed, and thought you might like to as well.  

For the link, click HERE. 

Shrink Rap and Guest Posts

We get a number of unsolicited emails every week from people offering to write guest posts for us.  They would like us to put their tag line on their posts, often links to websites having to do with getting online degrees or dental equipment or what have you.  The same sources often query us repeatedly.

This is just to make our policy on guests posts known: Shrink Rap does not accept guests posts from unsolicited sources.  Our guest posts are either written by people we have asked to contribute, or we've seen something that has been written for another venue and we ask for permission to reprint it here. 

How to Ask Your Doctor Intelligent Health Care Questions

Going to the doctor can be confusing.  Doctors make recommendations based on what they know, and patients are conditioned to trust their doctors.  While I think it's wonderful that patients trust their doctors, there are times when patients want more input into their health care, and if this is the case, then let me make some suggestions as to what might be important questions to ask.  There is nothing specific to psychiatry about my recommendations, so feel free to have these types of discussions with any doctor or prescriber.


If you go to the doctor for a routine visit and it is suggested that you have routine health maintenance tests or treatments and you are fine with that, then there is not much to ask.  If you have a concern about the necessity of a test or procedure, try to figure out what your concern is so you can verbalize it.  One example might be: Will routine vaccinations cause my child to become autistic?

• Why do I need this test?
• What is the risk of this procedure? 
• If a medication or supplement is being offered to decrease the risk of a specific illness later, then it's reasonable to ask if studies show that this treatment is known to be effective.  This may sound silly, but sometimes we just don't know things: so people took statins to lower their cholesterol, but it was a while before it was clear that they also lowered the risk of heart disease. And now the thinking is that Vitamin D and Calcium supplements may not lower the risk of osteoporosis in post-menopausal women (they may have other benefits however) but they do increase the risk of kidney stones. 

More importantly, if you choose not to follow your doctor's recommendations, ask:

• What are the risks of not taking this medicine/supplement/having this vaccine?

My favorite personal example-- when one of my children turned three, I took him to a pediatric dentist to start routine care.  The dentist told me it was standard procedure to x-ray a child's mouth at this age.  I wondered why-- if there are no obvious problems, their baby teeth are going to fall out anyway.  I asked and was told that they like to make sure the adult teeth are there.  Hmmm, how many people don't have adult teeth?  I didn't ask that, what I did ask was, "If you do an x-ray and find that there are no adult teeth, what can you do about this?"  The answer was, "Nothing, we just like to know."  So I'm no dentist, but my take on this was that the x-ray exposes my little person to radiation, costs money,  and if a problem is discovered, there is nothing to do to address it.  I verbalized this and the dentist was okay with not getting an x-ray.   


If you go to the doctor with a specific problem, things are a little different.  

• If the doctor orders a diagnostic test, you may or may not want to ask what he is looking for or trying to "rule out."  The answer may be something scary that is very unlikely and perhaps you may not want to know to worry about something that's not likely to be the problem.  

• Is it an option to treat a presumed illness without having a diagnostic test first?  If the treatment is something easy or benign or cheap or a lifestyle change, maybe it would make sense to try that before having an expensive or painful procedure.  If the test is being done to rule out a treatable form of a serious illness, then usually doctors do not like to delay a test.

• If the doctor recommends a specific treatment, it's reasonable to ask "How long it will take to work and when do you want to hear from me if things are not better?"  This is important, if you're supposed to be better in 3 days, you don't want to come back in 6 weeks saying you're still sick or hurting or very much worse.  And if the treatment is going to take 6 weeks to work, he doesn't want to hear that you're not better in 3 days.

• If you don't want the treatment your doctor recommends (or you're not sure), it's reasonable to ask: Are there other treatment options available?  What is the expected course of this illness/injury/problem if I don't have this/any treatment?  Sometimes the doctor won't know because different people have different courses with an illness and this can be especially true in psychiatry.

 Sometimes people go to the doctor because they are worried they have a specific illness and are then disappointed when the doctor does not order a test to look for that illness.  Sometimes the concern is 

• It's reasonable to say "I am worried that I have X, how can you be sure that I don't?"
• You might then ask, "Would it make sense to order X test?"  
• You might also ask, "If I continue to have these symptoms, are there diagnostic tests or treatment options that might be reasonable to try?"  And then ask for a time frame.

The truth is that doctors often don't have the answers to these questions, but sometimes it's helpful to hear their rationale for a decision or to let them know your concerns.  They certainly don't have crystal balls when it comes to issues of preventative care and risk, and often recommendations are made based on presumptions -- for example, people with sunburns get skin cancer, sunscreen prevents sunburn, sunscreen will prevent cancer-- before we can be absolutely certain that such logic will bear out.  And whether or not sunscreen prevents cancer, it might be nice to not be in blistering pain tonight regardless of long-term risk.

Bubbles or Bath Salts

A number of months ago, I had a massage.  It was very relaxing and my massage therapist suggested I take a bath with some special salts later that evening to "remove the toxins.
  In the lull of the moment, I spent $18 on a paper bag full off bath salts.  I used some once, but the truth is, I prefer bubbles.  Recently, there's been a lot of talk about bath salts in the news, a staff member at the Hopkins Press asked if I could talk on "bath salts and cannibalism" and I must say, I was completely confused.  I've finally figured out that "bath salts" have nothing to do with massages or baths tubs.  As I'm sorting this out, I thought I would share with you what I'm learning.


So "Bath Salts" are the street name for a mostly legal drug (now banned in some states, Denmark, the Czech Republic, or Sweden) named Methylenedioxypyrovalerone --MDPV.  MDPV can be purchased in gas stations and head shops.


On the website for the National Institute for Drug Abuse, director Nora Volkow, M.D. wrote last year:


These drugs are typically administered orally, by inhalation, or by injection, with the worst outcomes apparently associated with snorting or intravenous administration. Mephedrone is of particular concern because, according to the United Kingdom experience, it presents a high risk for overdose. These chemicals act in the brain like stimulant drugs (indeed they are sometimes touted as cocaine substitutes); thus they present a high abuse and addiction liability. Consistent with this notion, these products have been reported to trigger intense cravings not unlike those experienced by methamphetamine users, and clinical reports from other countries appear to corroborate their addictiveness. They can also confer a high risk for other medical adverse effects. Some of these may be linked to the fact that, beyond their known psychoactive ingredients, the contents of "bath salts" are largely unknown, which makes the practice of abusing them, by any route, that much more dangerous. Unfortunately, "bath salts" have already been linked to an alarming number of ER visits across the country. Doctors and clinicians at U.S. poison centers have indicated that ingesting or snorting "bath salts" containing synthetic stimulants can cause chest pains, increased blood pressure, increased heart rate, agitation, hallucinations, extreme paranoia, and delusions

The ingestion of bath salts is associated with raising body temperature, which may lead users to take their clothes off.  It was speculated that the man who was found naked and eating the face of another man on a Florida highway may have been using bath salts, though the latest of Googled articles states that this was not the case.  

In any case, the "bath salts" in the tub are different from the stuff in the news.  Stick with the tub stuff, the MDPV variety seem to be doing nothing good and are very dangerous.  

And yes, I'd love to hear your bath salt stories.