Hospital-Based Supportive Psychotherapy and the Biopsychosocial Model

Forty years ago George Engel, M.D., proposed the biopsychosocial model as a method for “understanding the determinants of disease and arriving at rational treatments.” Physicians were urged to consider their patients’ experience and social context as well as their medical findings.

In hospital-based psychiatric settings, such as inpatient psychiatric units and consultation/liaison services, supportive psychotherapy (SP) had been one of the most useful tools for delivering this comprehensive care. Changes in health care management, however, threaten the provision of SP. In the late 1980s the average length of stay on a psychiatric inpatient unit in a general hospital was 12.1 days. By 2008, the length of stay in a 39-state survey was eight days, with some states averaging as low as four days. By 2011, the average length of stay on a mental health unit fell to less than a week.

Consultation/liaison services are also facing decreasing lengths of stay on medical and surgical units. The brevity and intensity of modern hospitalizations along with the broadening range of somatic interventions may discourage providers from attempting psychotherapy. Nonetheless, SP remains a viable option in the hospital, especially among the seriously ill for whom a thorough assessment and management of psychosocial factors are required for comprehensive treatment.

Defining SP, the “Cinderella of psychotherapies,” presents an ongoing challenge that might best be met by examining its goals and techniques. SP focuses on optimizing patients’ overall functioning, self-esteem, affective control, cognitive functioning, and coping strategies. Sitting at the junction of the biomedical and psychosocial arenas, psychiatrists have an unequaled opportunity to provide SP. The supportive psychotherapist creates a stable environment in which patients can safely experience and express emotions, develop an awareness of their illness, and actively participate in their treatment (see figure box at right). The psychiatrist can adapt the interventions to make them familiar and compatible with the patient’s character structure. They foster a therapeutic alliance with explicit discussions of the roles and expectations of the therapist and patient who can collaboratively develop immediate and long-term goals.

Throughout the process, the psychiatrist displays empathy, respect, warmth, and positive regard while maintaining proper boundaries. These common elements alone often result in significant therapeutic benefits. The psychiatrist can assist patients in developing a coherent narrative encompassing their illness and circumstances. As patients review their lives, the psychiatrist helps them reframe their experiences in a more honest or positive light.

Psychoeducation can be used to increase awareness of their illness and treatment regimen. Adaptive coping strategies can be identified and encouraged. Plans to make healthy changes in behavior and lifestyle can be developed and praised. Exploration of existing social supports can lead to an identification of the most helpful relationships. Dysfunctional or self-defeating attitudes and behaviors can be directly, though gently, addressed.

Few studies have been designed solely to demonstrate the efficacy of SP, but it is commonly used as a comparator in randomized trials. Reviews of SP have shown it to be as effective as other therapies in patients with bipolar disorder, schizophrenia, phobias, and borderline personality disorder.

While other reviews have found superior efficacy among more specific psychotherapies, often the form of SP found in these trials is a “treatment without goals, organization, or any relation to solving the patient’s problems; it may essentially consist of being nice to the patient.” One recent Cochrane Review found no additional benefit from providing SP in the treatment of patients with schizophrenia, but this study’s definition of SP included interventions that required no training such as “befriending” and specifically excluded studies of interventions that sought to “educate, train, or change a person’s way of coping.” Informed psychiatrists use SP, however, to educate patients and change coping strategies.

Psychiatrists at Columbia University have developed a guide for SP in the hospital-based setting, the 3-Step Supportive Psychotherapy Manual. Deborah Cabaniss, M.D., and colleagues have distributed this through the American Association of Directors of Psychiatric Residency Training’s Psychotherapy Committee. The process starts with an evaluation that facilitates SP. The psychiatrist asks about key psychosocial issues such as coping strategies, affective and self-esteem regulation, and relationships with others noting both the patient’s strengths and weaknesses (see sidebar).

The psychiatrist works collaboratively with patients to develop realistic goals for treatment in the hospital. The goals may include establishing a solid therapeutic alliance, helping patients feel understood/validated through empathy, and optimizing social and medical support. The development of an accurate illness narrative diminishes patients’ sense of uncertainty and helplessness. As hospitalization is likely secondary to a crisis, the psychiatrist can help patients mobilize strengths and resources to address the crisis. After setting the goals, the psychiatrist chooses the therapeutic techniques most likely to attain those goals (see box at right).

Engel argued that “general competency for all health professionals would derive from their shared understanding that all three levels, biological, psychological, and social, must be taken into account in every health care task.” Psychiatrists should take the lead in providing this integrated care to patients hospitalized with mental illnesses. If mental health systems and leaders promote and model supportive psychotherapy in their workplace, we can fulfill the promise of the biopsychosocial approach. ■