Elements of Supportive Psychotherapy for High Impact Clinic Visits – Episode 2
In this episode, we explore how utilizing elements of supportive psychotherapy can help engage patients in short clinic visits.
Guest: Joe Harrison NP
Samantha Lau is an experienced board certified nurse practitioner in family medicine. She works as a manager of nurse practitioners in psychiatry/ behavioral health medicine in Southern California.
Welcome to Behavioral Health Radio Your resource for all things behavioral health. We are here to help educate and raise awareness of mental health care by helping clinicians challenge and broaden their current practices. Each episode features frank and enlightening talks with experts from every field of the mental healthcare industry. We touch upon everything from… What are the keys to successful psychopharmacology? What are some evidence based treatment solutions for achieving remission? How do you relate to your patients and form real therapeutic alliance Augmentation strategies? What are current best practices in psychotherapy? Let’s re-think what it means to deliver world class mental healthcare. This matters! So let’s talk about it!
Storytelling has been with us since the days of campfire and besieging wild animals. It served a number of important functions: amelioration of fears, communication of vital information (regarding survival tactics and the characteristics of animals, for instance), the satisfaction of a sense of order (justice), the development of the ability to hypothesize, predict and introduce theories and so on.
We are all endowed with a sense of wonder. The world around us in inexplicable, baffling in its diversity and myriad forms. We experience an urge to organize it, to “explain the wonder away”, to order it in order to know what to expect next (predict). These are the essentials of survival. But while we have been successful at imposing our mind’s structures on the outside world we have been much less successful when we tried to cope with our internal universe.
The relationship between the structure and functioning of our (ephemeral) mind, the structure and modes of operation of our (physical) brain and the structure and conduct of the outside world have been the matter of heated debate for millennia. Broadly speaking, there were (and still are) two ways of treating it:
There were those who, for all practical purposes, identified the origin (brain) with its product (mind). Some of them postulated the existence of a lattice of preconceived, born categorical knowledge about the universe the vessels into which we pour our experience and which mould it. Others have regarded the mind as a black box. While it was possible in principle to know its input and output, it was impossible, again in principle, to understand its internal functioning and management of information. Pavlov coined the word “conditioning”, Watson adopted it and invented “behaviourism”, Skinner came up with “reinforcement”. The school of epiphenomenologists (emergent phenomena) regarded the mind as the by product of the brain’s “hardware” and “wiring” complexity. But all ignored the psychophysical question: what IS the mind and HOW is it linked to the brain?
The other camp was more “scientific” and “positivist”. It speculated that the mind (whether a physical entity, an epiphenomenon, a non-physical principle of organization, or the result of introspection) had a structure and a limited set of functions. They argued that a “user’s manual” could be composed, replete with engineering and maintenance instructions. The most prominent of these “psychodynamists” was, of course, Freud. Though his disciples (Adler, Horney, the object-relations lot) diverged wildly from his initial theories they all shared his belief in the need to “scientify” and objectify psychology. Freud a medical doctor by profession (Neurologist) and Josef Breuer before him came with a theory regarding the structure of the mind and its mechanics: (suppressed) energies and (reactive) forces. Flow charts were provided together with a method of analysis, a mathematical physics of the mind.
But this was a mirage. An essential part was missing: the ability to test the hypotheses, which derived from these “theories”. They were all very convincing, though, and, surprisingly, had great explanatory power. But – non-verifiable and non-falsifiable as they were they could not be deemed to possess the redeeming features of a scientific theory.
Deciding between the two camps was and is a crucial matter. Consider the clash – however repressed – between psychiatry and psychology. The former regards “mental disorders” as euphemisms – it acknowledges only the reality of brain dysfunctions (such as biochemical or electric imbalances) and of hereditary factors. The latter (psychology) implicitly assumes that something exists (the “mind”, the “psyche”) which cannot be reduced to hardware or to wiring diagrams. Talk therapy is aimed at that something and supposedly interacts with it.
But perhaps the distinction is artificial. Perhaps the mind is simply the way we experience our brains. Endowed with the gift (or curse) of introspection, we experience a duality, a split, constantly being both observer and observed. Moreover, talk therapy involves TALKING – which is the transfer of energy from one brain to another through the air. This is directed, specifically formed energy, intended to trigger certain circuits in the recipient brain. It should come as no surprise if it were to be discovered that talk therapy has clear physiological effects upon the brain of the patient (blood volume, electrical activity, discharge and absorption of hormones, etc.).
All this would be doubly true if the mind was, indeed, only an emergent phenomenon of the complex brain – two sides of the same coin.
Psychological theories of the mind are metaphors of the mind. They are fables and myths, narratives, stories, hypotheses, conjunctures. They play (exceedingly) important roles in the psychotherapeutic setting but not in the laboratory. Their form is artistic, not rigorous, not testable, less structured than theories in the natural sciences. The language used is polyvalent, rich, effusive, and fuzzy in short, metaphorical. They are suffused with value judgements, preferences, fears, post facto and ad hoc constructions. None of this has methodological, systematic, analytic and predictive merits.
Still, the theories in psychology are powerful instruments, admirable constructs of the mind. As such, they are bound to satisfy some needs. Their very existence proves it.
The attainment of peace of mind is a need, which was neglected by Maslow in his famous rendition. People will sacrifice material wealth and welfare, will forgo temptations, will ignore opportunities, and will put their lives in danger just to reach this bliss of wholeness and completeness. There is, in other words, a preference of inner equilibrium over homeostasis. It is the fulfilment of this overriding need that psychological theories set out to cater to. In this, they are no different than other collective narratives (myths, for instance).
In some respects, though, there are striking differences:
Psychology is desperately trying to link up to reality and to scientific discipline by employing observation and measurement and by organizing the results and presenting them using the language of mathematics. This does not atone for its primordial sin: that its subject matter is ethereal and inaccessible. Still, it lends an air of credibility and rigorousness to it.
The second difference is that while historical narratives are “blanket” narratives psychology is “tailored”, “customized”. A unique narrative is invented for every listener (patient, client) and he is incorporated in it as the main hero (or anti-hero). This flexible “production line” seems to be the result of an age of increasing individualism. True, the “language units” (large chunks of denotates and connotates) are one and the same for every “user”. In psychoanalysis, the therapist is likely to always employ the tripartite structure (Id, Ego, Superego). But these are language elements and need not be confused with the plots. Each client, each person, and his own, unique, irreplicable, plot.
To qualify as a “psychological” plot, it must be:
In all these respects, a psychological plot is a theory in disguise. Scientific theories should satisfy most of the same conditions. But the equation is flawed. The important elements of testability, verifiability, refutability, falsifiability, and repeatability are all missing. No experiment could be designed to test the statements within the plot, to establish their truth-value and, thus, to convert them to theorems.
There are four reasons to account for this shortcoming:
So, what are plots good for? They are the instruments used in the procedures, which induce peace of mind (even happiness) in the client. This is done with the help of a few embedded mechanisms: