Defining supportive psychotherapy
Psychoanalytically informed supportive therapy is defined by its goals, its method, and its techniques because these differentiate it from expressive therapy. Granting that in everyday practice the distinction between the two therapy approaches is less sharp than it is in theory and that skillful therapists typically mix the two methods as indicated, it may be helpful to sketch out the theoretical differences between the two approaches as they are applied to the treatment of patients with personality disorders.
The goals of supportive therapy can vary from restoration and maintenance of functioning to fulfillment of whatever may be the individual’s capacities for happiness and healthy living. The latter is often referred to as "adaptation," a somewhat confusing term that often arouses the question, "adaptation to what?" The answer to this question is adaptation to whatever is irremediably limited by the patient’s circumstances. In expressive therapy, the therapist’s goal does not include maintenance of functioning, because patients referred for expressive treatment are usually seen as able to function on their own with only brief regressions during treatment. Verbalized insight, as well as adaptation, is a criterion of therapeutic success in expressive therapy, where the overall goal can be described as a general expansion of patients’ awareness of their inner life and of its manifestations in current feelings and fantasies. Behavioral change for the better is seen as a consequence of developing such insight.
The methods of supportive and expressive psychotherapy differ consonant with their differing goals. The basic strategy of supportive therapy is to create an atmosphere of safety within which the patient can work with the therapist to overcome the internal and external obstacles that prevent achievement of the patient’s goals. The basic strategy of expressive therapies is the creation of a treatment situation that highlights the patient’s transference wishes and fears. As supportive and expressive psychotherapy goals and basic strategies differ, so too do their methods—with expressive therapy relying on techniques that facilitate the interpretation of transference—and supportive therapy relying on maintaining a reflective state in which identification with the reflectiveness of the therapist is most likely to occur.
In treating patients with personality disorders, it is well to keep in mind that disturbances in the management of feelings is almost always a fundamental problem. To do useful work in therapy, patients must be helped with affect regulation, learning to tune affect down or up to produce the state in which they can attend and think. Therapy is best carried out with the patient in the quiet, alert state most conducive to learning, a concept derived from developmental psychology. Peter Wolff (1966) discovered, by continuously observing neonates over a 24-hour period, that they had six emotional states ranging from deep sleep to hard crying. One state, observable only fleetingly at first, was a quiet, alert state in which the infant attended to the outside world. Over the ensuing months this state became more frequent and prolonged, and it was in this state that the baby could play with the parents and learn about the world around it.
Supportive therapy with adults seeks to bring about the adult counterpart of the "learning state" so that the patient can learn to endure and ultimately enjoy interacting with the therapist in pursuit of the goals of therapy. These goals are determined in part by the amount of time the two participants have to work together: are they in a clinic where the treatment with any particular student must end in July? If so, there must be an initial discussion as to what goals can realistically be met in the time available. Initial goals are further determined by the patient’s aspirations and by the strength available to work toward those aspirations.
Some examples may be useful. The following examples are drawn from psychoanalytically trained therapists in private practice who formed a study group to learn more about supportive psychotherapy.
A 50-year-old dancer with narcissistic personality disorder came depressed to the therapist, lamenting the manifestations of aging that were limiting the parts she could play. At first she was full of self-contempt when she contemplated moving on to teaching, but with the help of the therapist she began to reminisce about all her own old teachers and how much they were respected by the dance aficionados of the time and idolized by their students. Over a period of 2 years she established herself as a teacher and regained her lofty charm.
The therapist’s help consisted of listening with interest to the many stories the patient wanted to tell and empathizing with her hatred of the inroads of age. The therapist chose this route because the patient’s self-centeredness, grandiosity, and inability to accept normal aging and its consequences seemed to be indications that the basic structure of her personality was too rigid and too delicate to sustain major change. The patient’s indifference to everything other than the world of dance, her lack of any but the most shallow relationships, her easy rejection of anyone who failed to admire her, and her dependence on dance as the major support of her sense of self further convinced the therapist that an expressive therapy seeking to explore the meanings of her narcissistic pathology would either require an inordinate length of time or would fail. The supportive approach rapidly resolved the presenting "depression" (better described as a monumental sulk, for there were no vegetative symptoms) and restored the patient’s legitimate pride in herself as a dancer.
A business consultant with a history of suicide attempts and considered to have a borderline personality disorder with narcissistic features, came to therapy because of chronic anger. He saw all his bosses as fools and his peers as idiots. He was fired repeatedly, as a consequence of obstreperous behavior in which he showed up the limitations of his supervisors in public. He had run up massive debts and was forced to live with his parents because he could not afford a place of his own. The therapist focused on the patient’s altercations with bosses, offering "lessons in hypocrisy." The patient drew himself up in righteous indignation, protesting, "Being a hypocrite is utterly against my principles!" "I didn’t say I would help you become a hypocrite," replied the therapist, "only that I could help you act like one for purposes of survival."
On this basis the patient agreed to begin treatment, pledging to confine his diatribes to the sessions. He soon got an excellent job and was not only able to keep it during the treatment but was promoted several times. The treatment gradually took on the qualities of a partnership in which there was a high level of mutual respect, and both parties were equally invested in sorting out the feelings that tended to build up to episodes of rage or desperation. The therapist made no attempt to explore the unconscious elements in their relationship, remaining confident that this young man’s partially formed identity would best be helped to solidify were he to become master of his intense affects.
The approach to this case is in contrast to how expressive therapy might approach this patient. Transference-focused therapy (Kernberg 1983), for example, would be alert to those moments when the patient’s rage and contempt would be directed toward the therapist (as was starting to happen in the "hypocrisy lesson" episode). The therapist would not offer "lessons" in the first place but instead would focus on the rage being directed at the therapist and then offer an hypothesis such as, "It’s as if the offer itself of help underlines the feelings of need that you are so ashamed of and makes you want to turn on your helper and make your therapist feel stupid and corrupt."
The following recommendations to therapists are about how to establish and maintain a "learning" state by keeping the patient’s anxiety at an optimal level. To implement this basic strategy successfully, the therapist must think analytically while maintaining an attitude of kind objectivity.
Attending to the patient’s physical comfort
To establish the learning state in the first encounter, the therapist tries to make the patient comfortable. Throughout the treatment, the therapist sees to it that there are no interruptions (Havens 1989). The therapist’s telephone and beeper are turned off, and if this is technically impossible the therapist explains in advance that the telephone might ring during the session but will not be answered unless, for instance, the therapist is expecting an emergency call. A "Do Not Disturb" sign is on the door.
Establishing and maintaining conditions of emotional safety
An atmosphere of emotional safety is fostered when the therapist lays out the conditions of treatment in clear and simple terms. The therapist must be explicit about what is needed from the patient to do his or her work effectively. He or she must unapologetically specify what can and cannot be done to make the patient feel better and what the patient must do to keep the treatment going (stay alive, avoid self-injury or actions like law-breaking that risk interrupting treatment, stop abusing mind-altering substances, and stay as fit as possible). The patient must try to be honest. Lies or withholding important information should be cleared up with the therapist as soon as possible. Both parties should be punctual and respectful of the constraints (e.g., time, money) that limit the other’s choices.
Early in treatment, or even before formally beginning, it is often wise for the therapist to meet with the family and the patient to explain the therapist’s understanding of the trouble, why supportive treatment is being prescribed, and how the family can help. Special psychological and neuropsychological testing is often indicated in these cases. The results and their implications for treatment should be shared with patient and family together, if possible.
The therapist maintains emotional safety by keeping a steady level of interest, while avoiding implicitly using his or her perceived superior power to influence the patient. Consider the following exchanges:
Patient: Mind if I turn this lamp off?
Note that the therapist does not regard every interchange as intrinsic to therapy but at certain times treats the patient as a guest; he or she does not look for concealed meanings in everyday requests; attempt to "clarify" with statements such as "I wonder why the lamp is bothering you today?"; "confront" with "That light has been on for 6 months—there must be something different about today"; or interpret with "Perhaps too much light was shed on the subject of your anger at me last time." Why not? The "clarifying" intervention implicitly informs patients not to ask for consideration in the sessions, which can have the unintended consequence of stifling the expression of wishful fantasies later on. The "confrontational" intervention embarrasses the patient and stirs up defensiveness, which should be kept at a minimum in supportive therapy. The "interpretation" implies (correctly, perhaps, but inappropriately for supportive therapy) that without knowing it, the patient is hiding something from himself and the therapist can see it. All three types of intervention disturb the relationship between patient and therapist by implying a power discrepancy that the patient feels but usually cannot describe because it is covert, implicit, and not openly acknowledged by the therapist. These three staples of psychoanalytic technique are designed to shake up the defensive structure of neurotic patients whose symptoms are frozen in that structure and who can endure the temporary disruption of the relationship with the analyst in the interest of eventually feeling and functioning better. The treatment of choice for personality disorders is supportive therapy, in which the triad of clarification, confrontation, and interpretation is used sparingly, if at all. This approach is particularly true of the early diagnostic phase, when the therapist is developing a preliminary understanding of the case.
Throughout the treatment, the therapist is aware that emotional safety is jeopardized by change in the immediate environment of therapy. If, for example, flowers appear suddenly on the coffee table, a patient may wonder—from whom? why now? Furniture is rearranged—for whose comfort? Christmas cards are displayed in the waiting room and office, and the patient thinks, "Should I have sent one?" Enhancing the patient’s awareness of the therapist’s interest in other people can stir a sense of rivalry before the patient is ready to deal with it. By the same token, therapists should avoid unnecessary contributions to the envy and sense of deprivation that most patients with personality disorders struggle with.
Interacting with the patient from the beginning
Interact with the patient from the start of therapy unless the patient launches into his or her story at once. Most patients with personality disorders react to a silent therapist with escalating anxiety, especially at the beginning of sessions. They may deal with their anxiety by asking the therapist to ask them questions. Often patients have been interviewed many times and have well-rehearsed answers for the standard questions of the psychiatric examination. They feel at home in the well-learned role of patient and provide the kind of answers most likely to result in whatever action they hope the therapist will take. A therapist seeking to develop a relationship with a new patient by asking questions may be in for an uncomfortable session of laconic responses or silence.
A direct question arouses defensiveness, and defensiveness interferes with the learning state. Asking a question is almost always an implicit assertion of power. Any therapist who doubts this dictum has only to reflect on his own feelings when his patient walks in and says, "How was your holiday? Nice tan, where did you go?" Many therapists feel quite uncomfortable. Some feel somewhat indignant at the thought that the patient is "turning the tables." After all, the therapist is the one who is supposed to ask questions; the patient is supposed to answer them. The questioner has the power, the other is endangered, defensive, or submissive and obedient.
Discrepancies of power are already implicit in the therapy situation for a number of reasons. First is the status of the therapist as an authority, and this status is often conflated with power by patients and therapists alike. Second, the patient nearly always meets the therapist on the latter’s turf. Third is the unequal flow of personal information from patient to therapist. Many patients with personality disorders resent and fear this power gradient because of the abuse of power they experienced in early life and because of the rage this experience filled them with, rage that feels as though it may spill over and destroy the relationship they need the most. To avoid adding to the humiliation and rage of the patient, wise therapists find ways of eliciting whatever information they need mostly without asking questions.
A gifted resident complained to her supervisor about a patient who would not answer her questions and thus was preventing her from "taking" a history. (Note the connotation of extracting information from an unwilling informant.) When the supervisor told her she could learn all she needed to know without asking questions, the resident was silent for a while and then said, "I feel completely disarmed." Shocked at what she had just heard herself say, she realized that she had been using questions as weapons to maintain her advantage as the doctor without acknowledging to herself how important it was to her that she be respected and submitted to by her patients. Hers was a covert need for power, and questions are a covert expression of that need.
When she next interviewed the patient she began with a statement: "It must be rough on you to be cooped up on a hospital ward on such a lovely spring day." The patient replied, "Actually, it doesn’t matter to me where I am or what the weather’s like. It’s like I’m crying inside all the time, and I don’t even know why." The diagnostic interview was well advanced by that one poignant response. The doctor had prompted the learning state required for meaningful discourse.
The novelist Canetti, in his book Crowds and Power, showed how the primitive origin of questioning is the need to determine whether the other is suitable as prey (Canetti 1962). Hence the primitive and all but universal reaction of anxiety when a question is asked, and hence also the dislike aroused in others by the person whose major form of social interaction is the question. True, there are innocuous, playful, and pro forma questions, but they are now part of therapeutic technique.
Responding to the patient’s questions
The latent aggression of a question is readily apparent to a therapist when the patient asks a question. The therapist may notice a feeling of discomfort, quickly dispelled by responding with "What brought that to mind just now?" Indeed, some therapists have been taught never to answer a patient’s question but to respond with a question instead. The patient gets the message that the question was "inappropriate"; becomes flustered, upset, embarrassed, and angry; and learns not to ask any more questions. If the patient does not have a severe personality disorder, the worst outcome of this little episode is the permanent stifling of questions, which makes the therapist more comfortable but may deprive the treatment of important data. The best outcome is that the patient is able to analyze the reaction and see how incongruent the sensitivity to the "superior power" of the therapist is to the current reality of the relationship. Patients with severe personality disorders are not so capable of useful self-reflection. With deep, if not murderous resentment of the capacity of others to exert power over them, with searing shame at the discrepancy of power and privilege between others and themselves, they react to covert expressions of the other’s power with rage, flight, or regression. "Responding" to questions does not necessarily mean answering them. The therapist may need to say at times something like, "I feel we don’t know each other quite well enough for me to feel easy about answering that question. I’d rather put it on the back burner for now and return to it later if it remains an issue."
Avoiding confrontation and interpretation
Avoid confrontation and interpretation, at least in the early stages of therapy. Ever since Strachey’s 1934 paper on the nature of the therapeutic action of psychoanalysis, psychoanalytically trained therapists have believed that analysis of transference is the intervention that brings about change. Without any scientific test of Strachey’s assertion, they have believed that the structural changes that are the substrates of enduring improvements will not develop in the absence of systematic interpretation of transference. Currently, researchers are beginning to address the question of whether the success of interpretive therapies, such as psychoanalysis and transference-focused psychotherapy, derives primarily from the verbal interpretive interventions of the therapist. It remains to be shown whether the supportive elements of psychoanalysis are themselves mutative in that they facilitate an interpretive process in the patient, reinforced by the developing identification with the therapist’s way of thinking about the patient’s trouble (Holinger 1999). The patient’s need to understand and integrate external and internal reality contributes to the motivation to pursue therapy. Yet that motive is impaired by anxiety, which is dealt with by the anti-integrative activity of splitting, the unconscious process that keeps bad, toxic, terrifying representations of self and other separate from good, rewarding, comforting ones.
Many psychoanalytic authors, including Appelbaum (1981, 1994), Dewald (1972), Gedo (1979), Holinger (1999), Loewald (1960), and Wallerstein (1986), have questioned whether interpretation is the only (or even the major) route to structural change. Changes referred to as "structural" when they come about in psychotherapy occur during normal development in the absence of interpretation but in the context of an environment that provides sufficient support to maturational processes. Children respond to the influence of their parents first by imitating them and gradually by internalizing aspects of the parents in the process of identification. Later they identify themselves with other important figures that come to stand for the parents. In health, as they establish these identifications, most children eventually develop a stable sense of self and ways of defending that effectively manage anxiety without sacrificing allegiance to reality; a firm yet benevolent conscience that produces signal guilt to prevent guilt-producing actions while permitting the reasonable pursuit of pleasure (change in the superego); and the capacity to love without fearing loss of the self in experiences of fusion and without excessive anxiety in the face of separations (reflecting change in both ego and superego). When such changes occur in the course of therapy the treatment is considered highly successful. As supportive elements cannot be entirely removed from transference-focused psychotherapy, a viable approach to the question of what brings about change in psychotherapy would be a treatment such as that described here that creates conditions facilitating the patient’s own interpretive work by supplying the conditions favorable to self-reflection.
Verbal confrontation and interpretation tend to increase anxiety and defensiveness, producing in patients whose personality is fundamentally sound a momentary disturbance in the relationship with the analyst. In analysis and expressive therapy, the frequency of sessions facilitates the prompt examination and repair of such ruptures, along with the mutual study of the origin of the defensive reaction. Patients with personality disorders, however, tend to regress when sessions are more frequent than twice weekly, and their tendency to distort relationships is generally so great that repair of ruptures can be the major ongoing task of the participants. Techniques that increase defensiveness are contraindicated in these cases.
Fostering verbal expression of thoughts and feelings
Patients with severe personality disorders are often extremely limited in the use of language. They are likely to say, "I’m upset" or "I’m having a hard time" to cover the whole range of painful, hostile feelings. Once the patient feels safe and welcome in the therapist’s presence, the therapist can begin helping the patient sort out and name her feelings. Pine (1985) has shown how moving from the "action mode" to the verbal mode of communication helps patients feel less alien.
Therapist: Maybe the upset has something to do with last night when you phoned me and I wasn’t there. That could be disappointing. Or it could be really scary.
Patient: No, I don’t think I was disappointed or scared.
Therapist: Could you pause for a moment before you go on, because I want to call your attention to two things I think are quite important. One is that you have gotten the courage to disagree with me, and it sounded like it was easy. And the other is that it is just as important to identify what you don’t feel as it is to get clear about what you do feel. We’ve been working so hard on naming your feelings that I think it’s worth paying attention to it when that starts getting easy.
Patient: Well, I can’t be too sure what I was feeling when I tried to reach you. But I know I was upset. My Mom had called...[she goes on to describe the disturbing phone call]. I guess it wasn’t so bad, same old thing, really. But when I hung up I cried a little and then I found myself dialing your number. Like I thought talking to you would sort of erase how bad my Mom had made me feel...like guilty, I guess. And just hearing your voice on the answering machine was comforting enough.
Notice that the therapist hazarded a guess about the upset: Why that particular guess? The patient had given so little information that the therapist did well to listen to her own feelings of guilt stirred by having been unavailable. Noting the complementary identification of neglectful mother/self with patient/baby (Racker 1968) provided information that could be used for a response ("listening to the countertransference"). The therapist took a chance on being wrong. Why not pursue the matter further before making a guess?—"Did something happen that upset you? What was it? Why was your Mom’s call so upsetting?"—but the therapist knew better and had no intention of derailing the interaction by questioning the patient, who clearly wanted to tell her story and would do so in her own time.
Finding something about the patient to like and respect
If finding something to like about the patient proves an impossible task, seek consultation and either discover what is of value at least potentially in the patient or arrange referral. Thomas Main (1960), who described the effect of borderline pathology among hospitalized patients on the hospital staff, observed the outward manifestations of splitting—each member of the nursing staff reacting to a different object relationship manifested in the patient’s reactions to him or her. The result was chaos in the staff that matched that of the patient’s mind. The remedy was for the staff to meet regularly to share impressions and develop a unified approach. This principle is valid today in the outpatient treatment of difficult cases. Forming a study group that meets regularly is a valuable protection against becoming exhausted and impatient in what can often seem a futile effort to help.
Keeping the end in mind from the beginning
Time-limited treatment is generally not good for patients with personality disorders. Current experience has shown that the most significant results of treatment (such as moving from disability status to full-time employment or finding a suitable partner instead of unstable, abusive ones) rarely show up before the third year of once- or twice-weekly sessions. This observation seems to reflect a response not so much to the number of sessions but rather the length of time the patient needs to have an ongoing relationship with the therapist before the therapist can become a stable internal object.
A dramatic example was a young man who, terrified of the feelings aroused in the therapy situation, canceled all but 28 of the 120 sessions scheduled for him. When he did attend, his participation was desultory, yet in his life he made considerable progress. The steady, undemanding attitude of a fatherly therapist set the patient free to try to fulfill his own ambitions, bit by bit, confident both of the therapist’s approval and the belief that his idealized therapist was absolutely dedicated to seeing the treatment through to its end. In point of fact, the therapist found it very difficult to sustain his undemanding position. He sometimes resented the patient’s casual manner of canceling sessions, and he believed keenly that the patient would make much better progress if he would attend every session. The study group supported the therapist through each crisis of frustrated therapeutic zeal and helped him remain patient while keeping an eye on how the patient was doing.
When a time limit is set by external policies or by the therapist’s life situation, it should be discussed with the patient before any commitment is made. Patient and therapist can then proceed to establish goals they can reasonably expect to meet in the time available. The therapist must keep these goals in mind. They may change, in which case a formal revision is in order.
At the halfway point of a time-limited therapy, patient and therapist should review their goals and adjust them, if need be, in light of how much time remains for them to be together. This review of what they have accomplished and what remains to be done is of immense importance given these patients’ difficulty with endings and therapists’ reluctance to inflict the pain of saying goodbye. It almost always comes as a shock to both parties to face the fact that ending will actually occur. Facing it early gives them time to express their feelings about it and to make plans as to whether and how and with whom therapy will continue.
A therapist whose patient was making good progress in a 2-year research project was reminded by the study group that she was several months beyond the halfway point of the treatment. The study group asked her what the goals of the treatment were and she replied, "Well, I know what my goal is, to help her free herself from her hostile entanglement with her mother...I’m not sure what her goal is." The group pointed out that the therapist’s goal was a very long-range one indeed; perhaps she and the patient could agree on a goal that had some chance of being reached in the 4 months that remained of the treatment. The therapist returned the next week to report that the patient’s goal was to take driving lessons! Actually this was quite achievable and not unrelated to the therapist’s ambitions for her.
In the training clinics of many teaching hospitals, patients are simply handed over from a graduating student to a beginner each July, an unfortunate practice that denigrates psychotherapy. "We’re just here to teach the residents," one patient said. "I get a lot more help from the receptionist than from my therapists. After all, she’s known all about me for years, and I know a lot about her, too. We talk about our grandchildren and about everything, I guess, and she never leaves." The practice of passing patients on deprives patients and therapists of the experience of ending as a serious matter. Furthermore, the strain on the therapist of ending all the cases at once is almost always excessive, resulting in emotional withdrawal and hasty planning just when patients most need a steady hand at the helm. It is much wiser to try to end cases when an ending of a phase of treatment comes about naturally.
Schlesinger (2005) described the "mini-endings" that occur in the course of treatment, not only in anticipation of weekends and vacations but also on the completion of a piece of work that leaves the patient feeling at loose ends for a while. The patient no longer knows what the treatment is all about, feels like canceling sessions, and in this mood is open to discussion of whether to go on or to take a break and decide whether to begin again. A fruitful discussion may ensue, leading to a real ending complete with an examination of the patient’s attachment to the clinic itself, to the routines that may have been laid down over years of clinic attendance, to the clinic staff that may have become a second family, and to the therapist. Parting, after this sort of discussion, leaves patient and therapist with the mixed feelings of sadness and pride in their accomplishment that are the hallmark of a true "commencement." The resident who says good-bye to the patients one by one as appropriate in the months before leaving the service finds time freed up to do evaluations, consultations, and referrals, an important part of the training of future therapists.
An example of an ending not attended to is that of a therapist who had the opportunity to work with a patient for 2 years in the clinic and thought they were making such excellent progress that they could continue in private practice after the resident’s graduation. The therapist mentioned this to the patient not long before a month-long summer break. When sessions resumed at the end of August, the patient seemed quite different. He had little to say and appeared to have lost interest in the issues they had been working on before. In November the resident took the matter up with the supervisor. "I’d planned to invite this patient into my private practice, but he’s turning out to be not nearly as intelligent and motivated as he seemed before. Actually, nothing has happened in the therapy since the end of August." "Nothing," said the supervisor, "doesn’t quite describe what looks like some sort of major signal of distress. Could your patient be worrying about the end of his treatment with you?" The resident brought the matter up in the next session, whereupon the patient’s eyes filled with tears. "When you didn’t say any more about my continuing with you after next June, I thought you must have changed your mind, and I couldn’t ask you because if you had changed your mind I wouldn’t have been able to stand it. Now it feels like a ton of lead has just been lifted off my shoulders." The treatment immediately resumed its former characteristics of vividness and fruitful interchange.
For personality disorders, indeed for all patients, supportive therapy as described here is the treatment of choice during the initial diagnostic phase. If relinquishing interpretation is the hallmark of supportive therapy, it would follow that the diagnostic phase is a period of supportive therapy. It is not so rare an occurrence that a patient pronounces his presenting problem solved at the end of the diagnostic phase and takes leave of the therapist before "starting treatment." Unaware that a successful piece of supportive therapy has been accomplished by accident rather than by intent, the therapist sees the patient’s leaving as "resistance" or a "flight into health" or the result of the therapist’s incompetence. The therapist may pursue the patient in the attempt to get the "real" treatment started. Such pursuit is usually not only futile but also harmful: "Am I really that sick?" the patient wonders. A good experience of therapy is thus transformed into one that stirs self-doubts and lessens the likelihood of the patient returning for another course of therapy in the future.
When the diagnosis of personality disorder emerges from the diagnostic phase, it is likely one will be dealing with special vulnerabilities and sensitivities, cognitive difficulties, malignant introjects, defective affect regulation, and identity diffusion to one extent or another. Different diagnostic patterns call for different varieties of treatment, as follows.
Paranoid personality disorder
Paranoid patients need individual supportive therapy as described in detail by Gabbard (2000), whose treatment recommendations closely resemble those described here. If the patient presents with major depression in which paranoid features are often prominent, the depression must be successfully treated before it is possible to make a diagnosis of personality disorder.
Therapists who undertake to treat a patient with paranoid personality disorder must be prepared for a long and arduous task that puts considerable strain on the therapist’s ability to contain and use his reactions to the patient’s unflagging accusations and suspicions. A nondefensive response, with steady effort to understand the patient’s point of view, may lead finally to identification with the therapist’s thoughtful interest. If so, the patient begins to see how the truculent, vigilant search for the venality of others has served as protection against feelings of worthlessness and vulnerability. At this point, the patient may become deeply sad, arousing in the therapist the wish to comfort rather than help the patient understand his or her sadness. In the absence of clear-cut vegetative signs, treating the patient for "depression" with medication is both ineffectual and counterproductive. It is an unspoken vote of no confidence both in the treatment and in the patient’s achievement of the ability to endure the sadness the patient has been defending against for years.
Paranoid patients have special vulnerabilities that must be taken into account. So great is their fear of others controlling them or seeing things that have escaped their own careful scanning that their defensive response to interpretation is particularly intense. They are prone to misunderstanding acts of kindness or words of encouragement as seductions.
A young woman rejected her therapist’s innocent offer to change the time of their appointments so that the patient could catch her bus, because it would require "payback." It later emerged that her father had bribed her for sexual favors.
Indeed, closeness in any form is intensely threatening to paranoid patients. An attitude of respectful reserve reassures them. Although one might start a session with a borderline patient with a warm greeting, such as "I’m glad to see you—I’ve been thinking a lot about our last session and wondering how it affected you," such a greeting would set a paranoid patient on edge: "What else has she been thinking? Why all the enthusiasm? What makes her think I was ‘affected’ by the session?" It is much wiser to greet the patient with a simple, "Good evening," offer a seat near the door, and await the barrage of reproaches.
Schizoid and schizotypal personality disorder
Supportive therapy is indicated for schizoid and schizotypal patients who challenge the skills of the therapist not by combativeness and suspicion but rather by silence, dismissiveness, and apparent indifference.
A young businessman, after several years of apparently superficial talking between long periods of silence, suddenly attempted suicide. Shaken, the therapist refused to resume the treatment after the patient’s discharge from the hospital. The new therapist found it difficult to be with the patient. His description of his childhood as in a world of stone seemed to fit the stony indifference, polite but distant, with which he treated the therapist. After several months he mentioned that he had always had an interest in sculpture and would like to take lessons. The therapist did not hear this unprecedented remark, and it would have gone unnoticed had the session not been recorded on audiotape. The patient never mentioned it again. When the young doctor informed him that he was moving away, he declined the offer of a referral.
The therapist had been lulled into indifference by the patient’s dismissive response to all his efforts to develop a relationship. The therapist never presented his uncharacteristic indifference as a problem to his study group, nor did he think about the patient much between sessions. The patient was succeeding in protecting his vulnerable feelings of worthlessness and longing with the façade of stony self-sufficiency. Just twice did he let down his guard, first with the suicide attempt and then with the risky remark about wanting to study sculpture. In supportive therapy, that remark would have stirred the alert therapist to respond (with care not to let too much enthusiasm frighten the patient away) that it might do the patient good to pursue that interest. Perhaps they could have a conversation about sculpture, he and this man imprisoned in a world of stone.
Borderline personality disorder
Borderline patients addicted to self-injury can benefit from a preliminary phase of education such as dialectical behavior therapy (Linehan 1993), which is of particular help in teaching patients that their illness is not their fault but is their responsibility, that they have to work to achieve what others develop naturally—namely, the ability to put their feelings into words rather than communicating in the language of action. Patients who come for therapy without such preparatory treatment will need a period of education about their illness and how to manage their behavior as the introduction to therapy. Once they have gained control over self-destructive actions, supportive therapy is the treatment of choice until a solid identification with the therapist’s reflective attitude has been achieved and along with it consolidation of a sense of self. At this point the termination phase of treatment can begin, a process that may lead to a decision to end treatment altogether or to referral for a more exploratory therapy.
Narcissistic personality disorder
Narcissistic patients can be exceptionally challenging, especially when their character includes paranoid and antisocial elements, the triad of malignant narcissism described by Kernberg (1989). Identification with the therapist may occur, if ever, very late in treatment, whereas superficial imitation that occurs early represents efforts to "have" what the therapist has, not to think or feel toward his or her own mind as the therapist does. Supportive therapy as described here may be effective with these patients, although an active exploratory therapy such as transference-focused therapy (Kernberg et al. 1989) is generally regarded as the treatment of choice.
Antisocial personality disorder
No psychoanalytically informed therapy has thus far been found effective for antisocial patients. It is therefore of special importance to make a careful, extensive diagnostic study of such cases to differentiate them from other personality disorders with antisocial features for which therapy may be effective if carried out in the hospital.
Histrionic personality disorder
Histrionic patients respond best to supportive therapy because, like borderline patients, they tend to communicate in the language of action (e.g., theatrical hyperemotionality, impulsiveness) and may require extensive supportive work before being able to express themselves in words. They are also given to the rapid development of erotized transference, responding poorly to attempts at interpretation (Blum 1973).
Hysterical personality disorder
Hysterical personality disorder was dropped from DSM-IV (American Psychiatric Association 1994), but these patients continue to present themselves for treatment nonetheless. They generally have symptoms related to the oedipal phase of development, tend to have strong interpersonal relationships, and tend to be thoughtful and introspective. Thus they respond well to expressive therapies, including psychoanalysis.
Obsessive-compulsive personality disorder
In general, patients with obsessive-compulsive personality disorder need psychoanalysis or expressive psychotherapy. Special care is required, however, in establishing the diagnosis before making a referral for such therapy, because in some cases the obsessional and compulsive symptoms serve to manage the intolerable anxiety of an underlying psychosis.
In all these cases, an initial trial of therapy without explicit verbal interpretive interventions may prove to be so effective that referral for the more costly and time-consuming interpretive therapies may not be necessary.
Avoidant personality disorder
The term avoidant personality disorder seems to describe a category of people who are constitutionally excessively shy, while longing for normal relatedness and fun (Kagan et al. 1988). Little evidence is available that one form of treatment is more effective than another in helping these patients overcome their fear of making fools of themselves in social situations. Common sense and anecdotal evidence strongly suggest that the kind of therapeutic relationship offered by supportive therapy, with a generous dose of ingenious cognitive-behavioral interventions, would be the ideal introduction to psychotherapy for these patients. Having developed some confidence in their ability to overcome their symptoms, they might well move into psychoanalysis to clarify the events and fantasies of early life that set the constitutional-genetic predisposition on the path of symptom formation.
Dependent personality disorder
A diagnosis of dependent personality disorder may well account for more rejections of patients by therapists than any of the other disorders. Gabbard (2000) has written a sensitive account of the feelings stirred in therapists by these patients, who present nakedly the wishes for unconditional care that most people succeed in defending against. A supportive therapy that accepts those wishes and tries to help the patient attain them without alienating others may succeed in easing the negative impact these patients have on others.
Patient: I don’t know if I can stand this treatment. I need contact. I was thrown out of dialectical behavior therapy for overuse of my therapist’s beeper, and thrown out of treatment with a therapist I really loved because I called her up all the time.
Therapist: Well, here we are, anyway, assigned to try to work together. I don’t have a beeper and sometimes don’t get to answer phone messages until late in the evening. But you may have learned more than you realize from your previous treatment. I am willing to see what we can do. You can call me any time and leave a message, and I’ll respond unless you tell me I don’t need to.
The patient called several times a day at first, but rarely asked to be called back. Therapy was successfully terminated as initially planned at the end of a year.
Most experienced, well-trained psychotherapists work for long stretches of time without seeking supervision or consultation. If they do so, it is all too often because a case has reached an impasse or is going badly. Therapists and their colleagues tend to connect supervision with failure, excessive dependency, or professional immaturity. Such derogation of supervision seems odd when one considers its honored place in other disciplines. Established actors continue to take acting lessons all their lives, as do accomplished dancers and musicians. In the medical profession a high value has somehow been placed on "going it alone," and this ethos seems to have infected the practice of many a psychotherapist.
Patients with personality disorders, and with identity diffusion and reliance on splitting as their major defense, present a therapist with challenges far beyond those to be expected when dealing with neurotic illnesses. Desperate suffering, anxiety that renders the patient almost unintelligible, importunate phone calls, self-injury, threats of suicide, dangerous behavior outside of sessions, even assaultiveness toward the therapist or—at the other extreme—withdrawnness, obscure communication, and lack of the expected feelings connected with horrendous stories are all behaviors that keep a therapist off-balance and uneasy, sometimes frightened and sometimes lulled into a state of indifference. The therapist can lose track of the goal of treatment and "go along" for months or even years with a conviction that the patient is a "lifer," needing endless contact with the therapist to stay out of trouble.
Working with some personality-disordered patients can be dangerous. Therapists must be prepared for threats of suicide, homicide, and assault. They may become the victims of stalking, lawsuits, or formal complaints of unethical behavior. In many if not most cases, such events are linked to therapists’ failure to think ahead and bring their concerns into consultation (Gabbard and Lester 1995).
A patient’s personality pathology can undermine the skills of an otherwise competent therapist. The therapists of these patients need a special form of supervision to avoid the pitfalls and impasses that the best of therapists can blunder into with patients with personality disorders. Although there is general agreement in the literature that individual supervision is necessary for therapists in danger of committing boundary violations, a case can be made for ongoing group supervision as the most effective way to keep the therapists of personality-disordered patients on track. In such groups different members respond to different facets of the patient, reflecting back to the therapist a more modulated and complex understanding of the case. A coherent theory of treatment with a well-articulated rationale is essential. It might be said that an effective study group is like an external representation of the internal integration we hope to help bring about in our patients.