Professional Documents
Culture Documents
002030
a shift of resources towards increasing its availability within the UKs National Health Service. Over
the past decade the pessimistic view of psychotherapy for elderly people has diminished owing to the
growing evidence base and the commitment of champions in old age psychiatry and psychotherapy.
However, there is still very little structured research into psychotherapy in dementia. Supportive
psychotherapy is a poorly understood but very practical means of helping people with dementia to
adjust to the effects of their illness. Its inherent flexibility enables individual sessions to be tailored
to the patients needs and deficits. An understanding of supportive psychotherapy and its benefits
could enable clinicians to improve the quality of life of people with dementia and their carers within
the ever-present constraints of limited time and resources. This article explores the use of supportive
psychotherapy as a treatment option in dementia.
Ola Junaid is a consultant in old age psychiatry in Nottingham (St Francis Unit, Nottingham City Hospital, Nottingham NG5 1PB, UK.
Email ola.junaid@nottshc.nhs.uk) and an associate postgraduate dean in the Trent Multiprofessional Deanery. His interests include
all aspects of dementia care, service provision and postgraduate medical education. Soumya Hegde is a specialist registrar in old age
psychiatry at Derby City General Hospital. Her research interests are alcohol misuse in elderly people and the non-pharmacological
management of dementia.
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Providing information
One of the first challenges in the management of
dementia is informing the patient of their diagnosis.
There continues to be widespread disagreement
among physicians and psychiatrists on what the
patient should be told. A pilot study undertaken
by Johnson et al (2000) found that only 40% of
medical professionals regularly disclosed a diagnosis
of probable Alzheimers dementia and only 25%
reported always using a clear terminology. It is
difficult to understand the reluctance to allow
autonomy to take precedence over paternalism. It
is clear from the work of Pinner & Bouman (2003)
that people with dementia want to have all the
information regarding their diagnosis. In their study
they found that 92% of patients with early dementia
wished to be fully informed.
The practice of any form of psychotherapy is
based on truth, a clear understanding of the ill
ness, its prognosis and management. Clinicians
who are responsible for disclosing and discussing
the diagnosis may well find that the principles of
supportive psychotherapy provide a very helpful
framework for therapeutic discussion.
What is supportive
psychotherapy?
Supportive psychotherapy is a rather neglected
aspect of psychotherapy, but we believe that it
is a particularly useful strategy that can play an
important role in positively influencing the quality
of life in those affected by dementia. Supportive
psychotherapy is not easy to define. In essence, the
therapist carries the patient, helps to sustain them,
bolster them.
Psychodynamically oriented
supportive therapy
In 1989 Rockland introduced the concept of psycho
dynamically oriented supportive therapy. As the
name implies, it is supportive psychotherapy of
an individual patient carried out according to
psychoanalytic understanding and psychodynamic
principles, by a therapist trained in dynamic
psychotherapy. Its immediate goal is to improve
ego functions, either directly, for example by
strengthening reality-testing or the ability to delay
gratification, or indirectly, by reducing the strain on
the ego from the id, superego and external reality.
All of this is in the service of promoting better
adaptation to both inner and outer worlds.
Rockland suggests that this type of therapy is
supportive because its main goals are the strength
ening of ego functions and the improvement of
adaptation, not the exploration of unconscious
conflict with subsequent insight.
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Components of supportive
psychotherapy
Rather than merely considering the theoretical
framework underpinning supportive psychotherapy
it may be helpful to look at what is actually done in
such psychotherapy.
Bloch (1979) gives a useful analysis of the key
components of supportive psychotherapy.
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Supportive psychotherapy
in practice
With limited and often reducing resources within
the National Health Service (NHS), mental health
services may find it hard to provide an expensive
psychotherapy for patients with dementia. So
extending supportive psychotherapy to include
these patients carers might seem to be out of the
question. However, the following anonymised
example from my (O.J.) own clinical work shows
its benefits to both parties. The NHS would do well
to take into account this important but neglected
area in its resourcing of services.
Case vignette: Mary and James
Mary had endured with considerable dignity signifi
cant disability consequent on severe cerebrovascular
disease. A referral to psychiatric services followed the
onset of a severe depressive episode. This responded
well to a course of antidepressants closely monitored
by a member of the multidisciplinary team. It became
evident over the course of her treatment that signifi
cant cognitive impairment was also present. Over the
next couple of years the focus shifted from managing
depression to managing dementia.
Eventually Mary developed severe vascular demen
tia. She has now lost the ability to communicate, and
is completely dependent on others for all her needs.
She has lived in a nursing home for several years and
is now confined to bed. Her husband James is a retired
professor who visits twice a day without fail. Unfortu
nately, his memory is beginning to fail and he is finding
it hard to negotiate the 10-mile round trip.
During a regular review he told me how they met
and how she gave up everything for him when things
were very hard for him. He said, She saved me and
now I cant save her.
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Conclusions
All psychiatrists practice supportive psychotherapy
some of the time. However, many might not have
considered the principles underlying this very
important aspect of clinical practice. Psychiatrists
need to develop a better understanding of this tool.
They need to improve their techniques and teach
others.
Do not be put off by the jargon. The literature is
accessible and not voluminous: for those who can
create a little time we suggest that it would be a wise
investment to explore it (Box 4).
The next step for the brave few might be initiating
a friendly discussion with local psychotherapists.
Regular supervision from a psychotherapy unit
might be a cost-effective and highly efficient use
of a scarce resource to disseminate knowledge and
expertise in what is a key area for all psychiatrists,
but a much neglected area for old age psychiatrists.
It is no longer enough to hold in mind patients with
dementia; psychiatrists have a duty to bring to bear
all the resources available to ensure that they make
a significant difference to the quality of life of these
individuals.
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Declaration of interest
None.
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MCQs
1 In managing dementia in elderly people:
a non-pharmacological interventions should be the last
resort
b psychotherapy services are easily accessible
c cognitivebehavioural therapy does not allay symptoms
of anxiety
d psychiatrists are sufficiently aware of existing psycho
therapeutic services
e psychotherapeutic approaches can help reduce anti
psychotic use.
2
a
b
c
d
MCQ answers
1
a F
b F
c F
d F
e T
2
a F
b T
c F
d F
e F
3
a F
b F
c T
d F
e F
4
a T
b F
c F
d F
e F
5
a F
b F
c F
d T
e F
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