Supportive Therapy in the Medically Ill: Using Psychiatric Skills to Enhance Primary Care

Prim Care Companion CNS Disord 2021;23(1):20nr02758

To cite: Welton RS, Crocker EM. Supportive therapy in the medically ill: using psychiatric skills to enhance primary care. Prim Care Companion CNS Disord. 2021;23(1):20nr02758.
To share: https://doi.org/10.4088/PCC.20nr02758

© Copyright 2021 Physicians Postgraduate Press, Inc.

^aDepartment of Psychiatry, Northeast Ohio Medical University, Rootstown, Ohio
^bUniversity of Iowa Hospitals and Clinics, Iowa City, Iowa
*Corresponding author: Randon S. Welton, MD, Department of Psychiatry, Northeast Ohio Medical University, 4209 State Rte 44, PO Box 95, Rootstown, OH 44272 ([email protected]).

CME Background

Articles are selected for credit designation based on an assessment of the educational needs of CME participants, with the purpose of providing readers with a curriculum of CME articles on a variety of topics throughout each volume. Activities are planned using a process that links identified needs with desired results.

To obtain credit, read the article, correctly answer the questions in the Posttest, and complete the Evaluation. This activity is free.

CME Objective

After studying this article, you should be able to:

• Implement elements of supportive therapy to address patients’ emotional responses to medical illness

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The CME Institute of Physicians Postgraduate Press, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation

The CME Institute of Physicians Postgraduate Press, Inc., designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note: The American Nurses Credentialing Center (ANCC) and the American Academy of Physician Assistants (AAPA) accept certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by the ACCME.

Release, Expiration, and Review Dates

This educational activity was published in January 2021 and is eligible for AMA PRA Category 1 Credit™ through February 28, 2023. The latest review of this material was January 2021.

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All individuals in a position to influence the content of this activity were asked to complete a statement regarding all relevant personal financial relationships between themselves or their spouse/partner and any commercial interest. The CME Institute has resolved any conflicts of interest that were identified. In the past year, Marlene P. Freeman, MD, Editor in Chief, has received research funding from JayMac and Sage; has been a member of the advisory boards for Otsuka, Alkermes, and Sunovion; and has been a member of the Independent Data Safety and Monitoring Committee for Janssen. No member of the CME

Institute staff reported any relevant personal financial relationships. Faculty financial disclosure appears at the end of the article.

Consultation and liaison psychiatrists and primary care providers (PCPs) know that mental illness is ubiquitous in the medically ill. As many as 29% of adults with a medical condition have at least one mental disorder.¹ In a study of low-income medically ill patients,² 25% percent met criteria for at least one Axis I disorder, while an additional 44% percent had subsyndromal mental illness. In that study, 14% of patients had subsyndromal depression, 17% were significantly anxious, and 30% were problem drinkers. These problems continue throughout life. In a survey of older adults in primary care,³ depressed mood was reported by 18%, insomnia by 26%, and morbid/suicidal ideation by 6.9%. These symptoms had been present for at least several days during the previous 2 weeks. Of the 43% of individuals who had experienced a loss over the previous year, 36% remained affected by the loss. Anxiety symptoms (29%) and PTSD symptoms (14%) were also common. Two-fifths (39%) of patients reported drinking alcohol in the previous week, with 18% drinking on more than 5 days and 13% having more than 3 drinks per sitting. While PCPs receive training in the medication management of these conditions, they are far less familiar with potential psychotherapeutic interventions.

It has been noted that PCPs can realistically integrate brief supportive therapy interventions into a busy clinical practice setting, and the literature shows that many health outcomes can be improved when these strategies are implemented. PCPs working intensely with patients on inpatient units or working with them over time in outpatient clinics can implement these strategies. Consultation and liaison psychiatrists can play a vital role in helping PCPs master the basics of supportive therapy, better preparing PCPs to address the challenging emotional responses to illness that can impact medical outcomes.

Supportive Therapy Basics

Supportive therapy is a practical and flexible set of psychosocial interventions in which the patient and provider work collaboratively to reduce distress and enhance functioning. The goal of supportive therapy is to increase the patient’s ability to use their strengths, engage effectively with sources of social support, and practice adaptive strategies to cope with problems. Supportive therapy assumes that all people possess skills and coping strategies that can be overwhelmed at times by circumstances. When individuals are overwhelmed, they have difficulty mobilizing these skills and strengths, have a reduced capacity to process complex information, and may feel unable to help themselves. Often, medical providers become so focused on their patients’ immediate symptoms and distress that they do not take the time to learn about and focus on patients’ preexisting strengths and positive attributes. A supportive therapy approach empowers providers to focus on the patient’s abilities and resources and helps the patient mobilize these effectively to better tolerate emotions, solve problems, cope with difficulties, and enhance social support.

Supportive therapy can be used to help patients manage distress and impairment from temporary stressors or circumstances or from ongoing difficulties such as chronic illness. Despite having been historically considered a therapy only for lower-functioning patients, supportive therapy is in fact a versatile treatment approach that can benefit patients with a wide variety of diagnoses and levels of functioning and can be provided in a broad array of clinical settings.^4,5

Evidence for the Use of Supportive Therapy in Medical Illness

While it is true that supportive therapy’s efficacy has been demonstrated for a broad variety of psychiatric illnesses, supportive therapy has also been shown to provide benefit for patients who are dealing with medical illness. We searched PubMed using the following strategy (supportive therapy[ti] OR supportive psychotherapy[ti]) AND (psychiatry OR psychiatrist OR psychiatrists OR psychotherapy OR psychotherapies), limiting results to articles published in English between 1980 and 2019, and obtained 133 results. We reviewed the articles for those related to medical illnesses. From the relevant articles, we then utilized cited reference searching to find additional relevant articles. The literature shows that supportive therapy decreases both morbidity and lengths of stay in patients admitted for medical and surgical diagnoses.⁶ Studies of supportive therapy have demonstrated benefit for patients with a wide range of medical illnesses, including peptic ulcer disease,⁷ irritable bowel syndrome,⁸ coronary artery disease,^9,10 ovarian cancer,¹¹ breast cancer,^12–15 prostate cancer,¹⁶ and chronic pain.^17,18

Due to its inherent flexibility, supportive therapy can be practiced within busy clinical environments such as hospital units; it has been noted that primary care providers can realistically provide brief supportive therapy interventions within their clinical practice settings.^6,19–21 In fact, supportive therapy is the form of psychotherapy that is used most frequently in medical settings.^22,23

One of the central goals of supportive therapy is to help patients improve their social support, which can directly improve both emotional and physical health. The positive impact of social support on emotional and physical health has been well documented over the years.²⁴ Patients with greater social support have been shown to experience a decreased perceived severity of pain^25,26 and a diminished physiologic response to stress.^24,27,28 Additionally, these individuals have lower blood pressure, improved wound healing,²⁹ a stronger immune response,³⁰ and decreased morbidity and mortality rates.^30–32 The caliber of evidence linking mortality with social support was similar to that found with standard risk factors such as smoking and physical activity.³⁰ Therefore, providing supportive therapy as part of a comprehensive biopsychosocial treatment approach can optimize patients’ medical outcomes along with their psychological functioning.

Supportive Therapy Techniques in the Medically Ill

Providers offering supportive therapy can focus on 4 general goals of treatment. They will help patients do the following:

• Identify and tolerate their emotions
• Develop a realistic, healthy narrative about their condition
• Cope with external stresses
• Engage support systems³³

Identifying and tolerating their emotions. Patients may experience emotional symptoms as a consequence of preexisting mental conditions or as a response to their medical problems. Often, these emotions can be confusing or overwhelming for patients. The provider can explore the patient’s emotional response and develop a shared vocabulary for the patient’s experience. Clinicians’ attempts at empathy, expressing an understanding of another’s emotional experience, help patients feel understood and over time help the provider and patient to understand the patient’s less obvious feelings and responses.³⁴ Chronically ill patients have often been treated by medical systems in a way they perceive as impersonal and uncaring. Having a provider who seems eager to work with the patient can be an exciting new experience. Inquiring into the patient’s strengths and past successes demonstrates a respect for them and can be a building block for future interventions. Patients respond to medical conditions in a variety of ways. Providers should validate and normalize the patient’s emotional response when possible. Recognizing that others might feel the same thing helps individuals “own their feelings” and decreases a sense of isolation, eg, “I know you must be worried. Anyone would be in your situation.”

Developing a realistic, healthy narrative about their condition. Patients and providers naturally focus on the immediate medical problem at hand. Taking the time to ask about other aspects of the patient’s life helps them feel respected and puts their illness into a proper context. Their illness and/or crisis may be a large part of their life, but it is not the entirety of their life. A variety of techniques can help the patient organize their experiences. Providers can simply encourage patients to elaborate on their story and experiences. Doing so can be as straightforward as asking patients to “Tell me some more about that” or echoing what the patient has just said as they explain their situation. Providers should occasionally paraphrase the patient’s story to help ensure that the patient feels listened to. As the provider tells the story, there will often be obvious gaps in their knowledge. They can simply ask for the missing information or, if time is short, highlight this gap and postpone the discussion until the next appointment. If the discussion is postponed, the provider will need to leave themselves a reminder to ask about it. Following up with a previous line of questioning not only creates a more complete narrative, but also conveys to the patient that they are important to the provider. Clinicians should also take time to thoroughly and systematically provide education. Patients may not automatically or correctly link their life and emotional experiences to their mental or medical illness. For example, many patients may categorize their lack of drive and motivation as a moral failing rather than as a treatable symptom of depression. Elderly patients might be relieved to know that their problems with memory and concentration may be related to their anxiety and are not necessarily a sign of dementia. Topics of psychoeducation should include the following:

• Reviewing the standard signs and symptoms of their illness
• Demonstrating how the general diagnostic criteria have been demonstrated in their life
• Describing the typical course and prognosis of their illness
• Reviewing the relative risks and benefits of a variety of treatments including psychopharmacologic, psychosocial, and complementary/alternative medicine options
• Warning patients of common comorbid conditions
• Discussing the value of limiting or eliminating the use of alcohol or other illicit substances³⁵

 Coping with external stresses. Coping strategies can be thought of as volitional or habitual responses to external stresses. Often, the coping strategy is one that has been successful at some times or in some situations, but patients may cling to obsolete coping strategies. After listening to how the patient responds to their circumstances, the provider can help them look for more effective ones. This can be done by highlighting what has worked for the patient in the past. Providers can ask the patient how their strengths and resources have been used to overcome troubles in the past, eg, “I know the nausea that follows chemotherapy can be awful and you are worried about how you will take care of your kids during that time. Well, you must have been sick in the past. What did you do with your children when you were down with the flu?” As the patient attempts new coping strategies, the success of these strategies can be discussed at subsequent appointments.

Psychoeducation can be used to promote treatment adherence. Discussions of treatment adherence can start with the benefits and proper way of taking medications. Patients should all have a clear understanding of the difference between regular medications and as-needed medications. Adherence is improved when providers discuss likely side effects and inquire about them regularly. To ensure that patients truly understand their medication regimens, the physician can ask them to explain when and why they take their medications.

The provider can use their benevolent authority to promote healthy lifestyle regulation. Promoting proper sleep hygiene, helping engage in regular exercise, limiting intoxicating drugs, increasing medication adherence, and improving diet can all result in benefits to patients’ mood and function. The health care team can monitor the success of these efforts over time by asking the patient and by direct measurement, eg, weight, blood pressure.

Patients with troubling life situations or severe limitations often feel powerless. They may never have learned efficient problem-solving techniques or may be hindered in using them. The provider can work with them to improve problem-solving skills. Problem solving starts with a realistic assessment of what is, and is not, within the patient’s ability to control. The provider can encourage the patient to write out a list of options and assess the pros and cons of each. Developing these skills will help the patient with their current problems and with future ones.³⁶

Anticipatory guidance helps patients prepare for potentially problematic future events. Based on the provider’s understanding of the patient’s situation and illness, the provider can anticipate situations that will very likely be difficult for the patient. These problems could involve physical limitations, physical discomfort, emotional reactions to changes in relationship, or upsetting anniversaries, eg, “Unfortunately, Ms Smith, you will still be in the hospital this weekend. That means you will have to miss your granddaughter’s graduation. I am sorry you will miss that ceremony. Have you given any thought to other ways in which you might celebrate with your family?” After discussing the problem, the provider can help the patient generate possible strategies for dealing with the situation. Once a strategy has been determined, the response can be practiced in the session, allowing the patient to gain a sense of mastery.³⁷ Over time, the patient can learn to perform all of these functions on their own and begin to anticipate and assertively respond to potential future problems.

Individuals who struggle with mental or medical illness are often saddled with hopelessness about their condition and the future. This hopelessness constricts their ability to see possibilities and options for themselves. While being careful not to present unrealistic outcomes, the provider can reassure the patient that improvement is likely (or at least possible) and that the provider will be there with them during their journey. As opportunities for change and improvement arise, reasonable hopefulness can also be shared. Just realizing that there are options available and that the provider is there to work with them can increase hope.³⁸

Engaging support systems. Often, patients going through severe medical or mental illness can feel alone or even isolate themselves. As has been discussed, social support is an effective strategy for improving medical and mental health. Providers should help patients focus on assessing the significant relationships in their lives. The provider can encourage patients to optimize those relationships that are supportive and nurturing while minimizing interactions that are perceived as toxic. Sometimes, there are disease-specific support groups (eg, for cancer survivors), and patients can be repeatedly encouraged to attend these. Many patients can find acceptance and support through religious groups and meetings. Others can be encouraged to seek out hobbies and interactions through enjoyable activities such as college classes or those offered at community centers. The provider will need to be diligent in these recommendations, as the patient’s natural response will be to do nothing. With continuing encouragement, the patient might be open to attending as an experiment, eg, “Ms Jones, you have said that you always enjoyed art. The senior center by your home is offering free art lessons. I know you are worried that your skills are not developed and that you might not fit in. How about if we agree to this? Try it twice as an experiment. We will talk about it at our next visit. If it as a positive experience, then you keep going. If you did not like it, you don’t have to go back. You are only committing to two hours, and I am hopeful that you will find it extremely rewarding. Can you commit to two sessions?” The PCP will be able to help the patient judge the success of these experiments at subsequent appointments.

Conclusion

Supportive therapy is an effective technique for patients with medical and mental illnesses. Consultation and liaison psychiatrists and PCPs can use supportive therapy to address patients’ emotional and mental response to illness and to help those patients cope with their ongoing illness. The techniques are practical and immediately beneficial and can be included in any therapeutic encounter. PCPs can learn and practice these simple techniques to provide a full range of biopsychosocial care to their patients.

Submitted: July 20, 2020; accepted October 6, 2020.
Published online: February 18, 2021.
Disclosure of off-label usage: The authors have determined that, to the best of their knowledge, no investigational information about pharmaceutical agents or device therapies that is outside US Food and Drug Administration–approved labeling has been presented in this article.
Financial disclosure: Drs Welton and Crocker have no personal affiliations or financial relationships with any commercial interest to disclose relative to the article.
Funding/support: None.

Clinical Points

• Using supportive therapy techniques can improve the care given by primary care providers.
• Supportive therapy helps patients tolerate their emotions, develop a narrative about their condition, cope with external stresses, and engage support systems.