Phases of Treatment
In early stages of treatment, much time is spent dealing with suicidality--with self-injurious behavior being a key aspect--and helping patients to develop more adaptive alternatives. Other aspects include dealing with derealization/dissociation, idealization/devaluation, harsh self-evaluation, and anxiety and depression. Later in treatment, therapists focus on helping the patient develop positive aspects of their life-working on relationships, improving work functioning, and establishing and maintaining positive feelings about themselves. In this phase, patients may benefit from naming feelings ("when he speaks to you like that, it sounds like you feel enraged"), from anticipatory guidance ("you dealt with that very well last time, how would you like to address it next time?") and from offering control ("you can choose to walk away at that point, rather than to answer back"). Many patients find their intimate or work relationships improving over time, which gives them increased confidence.
Finally, given that our research study is based on a one-year treatment, there is the issue of termination. In supportive therapy, the therapist works to help the patient not regress around this phase. This includes a realistic discussion about the ending of the therapeutic relationship and the feelings that the patient may have, as well as planning for further treatment. Supportive therapy differs from many other treatment approaches in working to normalize and contain (rather than explore) the feelings around this phase of treatment. Patients are completing a "course" of treatment--they may take many such courses in life (similar to college courses) and the goal is to take something away from the treatment experience that may be useful in later life.
As our supportive-therapy treatment approach has developed, it appears to us that it remains within the umbrella of Pinsker's and Novalis' models. In general, the types of interventions used are ones that are standard with other populations, but we obviously have modified them to deal with individuals who may be volatile, fearful and impulsive. Perhaps most notably, there is the constant challenge of developing (and maintaining) the therapeutic alliance with patients with BPD. With patients who have Cluster C PDs the therapeutic alliance may not involve continual attention, whereas with patients with BPD the supportive-therapy therapist must constantly modulate distance from the patient, trying to not be too close, yet not too far. Otherwise, the patient may decompensate or flee from treatment. Therefore, our current model of supportive therapy is probably more relational than Pinsker's original definition. In its continual work on reframing and dealing with black-and-white thinking, it may have more of a cognitive slant as well.
It is also becoming clear that once-a-week supportive therapy is not suitable for every patient with BPD. While many patients make significant progress, for others, a once-weekly approach appears to be insufficient. Such individuals may need more frequent visits, day-treatment programs, family interventions, inpatient hospitalization or more aggressive medication treatment (Jacobs et al., 2003; Oldham et al., 2001). Nevertheless, at present it seems that supportive therapy may work for many (if not most) people with BPD in terms of engaging them in treatment, developing a good therapeutic alliance and working to attain treatment goals. This is all an impression, of course; we await our study's outcome data.
At this point, however, our impression is that supportive therapy may be useful both for research and for clinical settings. In research, supportive therapy may be a good treatment to compare to other approaches--it appears quite different from other approaches such as DBT or psychodynamic treatment. To truly demonstrate the superiority of a specific psychotherapeutic approach such as DBT, it makes sense to compare it to a disciplined, well-defined standard treatment approach, such as supportive therapy, rather than to poorly defined clinical management. Beyond that, it seems to us that in clinical settings, supportive therapy is a logical type of treatment to use with individuals with BPD. Not all patients with BPD would agree to take part in DBT, for one; also, supportive therapy may be easier and more intuitive for clinicians to learn. Psychiatry residency training now requires supportive-therapy supervision and training, so there will be a growing cohort of psychiatrists trained in this technique who could learn to adapt it for patients with BPD.
In conclusion, after three years, our clinical impression is that supportive therapy may be a promising treatment approach for patients with BPD. It appears to be adaptable for many treatment settings and probably is better than having an unfocused, eclectic approach with poorly defined goals and therapeutic interventions. Given findings from a longitudinal study of outcome in BPD (Stone, 1992), the flexible yet disciplined approach of the supportive-therapy therapist may meet the evolving needs of this population on a long-term basis.
Have we just reinvented handholding? Our guess is that we may have refined a treatment approach that is beneficial and effective. But clearly more data should be obtained.
This research was supported by NIMH Grant RO1 MH 57469, awarded to Barbara H. Stanley, Ph.D., in the division of neuroscience at the New York State Psychiatric Institute.
Dr. Hellerstein is clinical director of the New York State Psychiatric Institute and author of the upcoming book A Guide for the Journey, which focuses on new psychiatric treatments.
Dr. Aviram is a research scientist in the department of neuroscience at the New York State Psychiatric Institute and a psychotherapist in the supportive-therapy cell of the NIMH-funded grant discussed in this article.
Dr. Kotov is a research scientist in the department of neuroscience at the New York State Psychiatric Institute and a psychotherapist in the supportive-therapy cell of the NIMH-funded grant discussed in this article.