Supportive Psychotherapy and Chronic Pain Primary Care

Lindsey Enoch, MD

Robert M. McCarron, DO, DFAPA

Christine Kho, MD

OVERVIEW

Patients present to their primary care doctors with many complex problems such as chronic physical pain. Among the most challenging patient encounters include those with comorbid and psychiatric or psychosocial concerns. Many providers feel they lack the resources, time, or skills necessary to address these kinds of issues. Yet with so many patients unable to access mental health specialty care, primary care doctors are often first-line in treating mental illness and guiding their patients through everyday conflict and distress.

In this chapter, we will introduce the principles and techniques used in supportive therapy. These techniques, which can be learned and applied over just a few appointments, are effective in managing a variety of complex issues seen in primary care. By learning these skills, primary care providers can provide substantial and effective treatment to patients unable to access other forms of mental health care or social support. They are also incredibly useful for patients with mental illness who refuse, fail, or have contraindications to psychotropic medications. Moreover, supportive psychotherapeutic techniques can also be utilized in the busy primary care setting.

Conditions that can be addressed with supportive therapy techniques:

Depression
Anxiety
Chronic pain
Problems with relationships, employment, housing, and other social stressors
Grief
Substance abuse
Recurrent hospitalizations or noncompliance
Stress related to general medical problems
Difficulties adhering to the treatment of general medical problems

First, we will review the evidence and core principles in supportive therapy, with particular focus on building coping skills. Next, we will provide a practical approach, showing how to structure appointments so that you can use these tools effectively in just 2 to 4 visits. Lastly, we will go over a case vignette that illustrates how and when to use supportive psychotherapy.

EVIDENCE

Historically, supportive therapy has been considered a nonstandardized form of therapy, making it difficult to reproduce and study against other forms of treatment. Although large randomized trials are lacking, there is evidence that it can be effective for a variety of patients. In a recent meta-analysis by Cuijpers et al., authors found that supportive therapy was as effective for treating depression as medications and other types of therapy.¹ In another study looking at treatment of depression in primary care, authors found that problem-solving therapy and interpersonal therapy, which use many of the same
techniques and principles as supportive therapy, were more effective for treating depression than medications and other types of therapy.²

There is also evidence that some of these therapeutic techniques can benefit patients after just a few visits, and even when provided by non-mental health professionals. In a systematic review by Nieuwsma et al., authors found that even brief therapy was effective for the treatment of depression in primary care. Many studies included used protocols with only six 30-minute sessions provided by non-mental health professionals.³ Though this study excluded supportive therapy, these findings suggest that primary care doctors can effectively learn and use therapeutic techniques to treat depression in the context of chronic pain, even when delivered in a busy general medical setting.

CORE PRINCIPLES

Broadly speaking, supportive therapy works by helping patients increase healthy coping skills and decrease unhealthy coping skills. Put another way, providers can help patients self-identify and utilize existing healthy coping strategies, while encouraging patients to recognize maladaptive coping mechanisms and replace with new strategies to address life stressors. By learning and applying healthier coping skills, patients can manage problems more effectively and with greater sense of control. This leads to increases in function and higher self-esteem. Also, these valuable skills can be used for a lifetime.

The acronym “PARENTS” will help you remember the core principles and skills needed to provide effective supportive therapy. First, we describe the theory behind each core principle, followed by the tools you will need to apply them.

PARENTS

Problem focused

Ally with patient

Recognize emotions

Enhance coping

Normalize

Teach

Self-esteem

Problem Focused

In supportive therapy, it is important to first identify a specific problem to treat. When patients come in with broad complaints such as “life is awful,” it is important to identify a more specific problem contributing to this belief. When there are numerous, or large, complex problems, break things into smaller pieces and address whatever is most pressing. Focus on the details of the specific problem, noting any contributing factors, associated symptoms, etc. In addition to understanding the problem better, asking for details like this will help patients “connect the dots” between symptoms, problems, or other key factors. Be sure to ask for the patient’s goals for addressing the problem, which is what your supportive therapy and their coping skills will be working toward. Help them identify a goal, making sure it is realistic and could be achieved after the next few visits.

Tools to Use:

Socratic questioning

Ask open-ended questions.
Identify triggers, symptoms, and associated dysfunction.

Example of provider response: “You’re really struggling with your anxiety. Tell me how that’s affected your life and your back pain?”

Determine a goal

Make it realistic, concrete, and time-limited.

Example: If a patient says the goal is to be “pain free” (which may be unrealistic), it is better to identify a functional goal, such as getting back to work (concrete). You might say, “Getting your pain under control is really important. What would you like to do if you could be pain free? It sounds like work is important to you, and something we could work toward accomplishing over the next few visits. I think that would help you feel better in a lot of ways. What do you think?”

Summarize

Confirm your understanding.
Make connections they may not have seen.
Use this approach as redirection when patient getting off topic.

Example of provider response: “You’re having a lot of pain and trouble just getting through the day. There are a lot of different stressors weighing on you, and you’d like better pain control so you can go back work.”

Ally with Patient

Supportive techniques are most akin to being a “good parent.” Listen, empathize, and advise when necessary, but without directly providing an answer or solution. It is usually more effective to lead the patient to self-discovery of a workable solution. Ask about the problem, and try to listen to the patient without initial interruption. Although listening can sometimes seem too passive to be effective, many patients lack a safe place to express their feelings and concerns. In many clinical situations, silence on the part of the provider is therapeutic and, although likely foreign to patients, will often be welcomed and is evidence of genuine interest and investment of time for the patient by the provider. Building rapport and expression of interest in a patient with high levels of psychosocial stress will take time but will most often yield positive results, including improved adherence to mutually agreed-upon treatment plans.

Tools to Use:

“2 ears, 1 mouth rule”

For at least 5 minutes, try to listen without interruption.

Show support

Show interest with engaging body language (e.g., nodding in agreement, making eye contact, avoid crossing arms).

Be empathic

“Become the patient” or understand the emotional state and life circumstances as best as you can.
Demonstrate genuine empathic remarks.

Example of provider response: “You’ve endured a lot with your husband, and you’ve really tried your best. I’m glad you’re telling me this.”

Recognize Emotion

Oftentimes when people are distressed, they disconnect and misidentify their feelings. In almost every condition we listed above, patients have trouble recognizing, accepting, or articulating their emotions. Any emotion can become debilitating and difficult to manage when not clearly understood. In supportive therapy, the task is to help patients recognize and understand their emotions and connect them to the problem being discussed. With better emotional awareness, patients can cope more effectively and appropriately, which will lessen their distress. You can help the patient develop this valuable skill by inviting them to reflect on their emotions in the specific problem being discussed.

Tools to Use:

“And how did that make you feel?”

Ask and ask again. People have lots of emotions and often need a few chances to recognize them.
Use this approach when patients get overly focused on what happened (rather than why it is bothering them).

Example of provider response: “Did you have other feelings about this? Like what? What else?”

Name the emotion

Suggest a “normal” emotional response when applicable (e.g., grief reaction).
Ask patients to identify the emotion when challenging for them to do so.
Use this approach to clarify and simplify complicated experiences.

Example of provider response: “Wow, it sounds like you were really scared!”

Objective interpretation

Suggest a more accurate emotion or interpretation when applicable.
Use when:
- patient’s feeling/interpretations differ significantly from your understanding of the problem
- their “misinterpretation” is interfering with resolution of the problem

Example of provider response: “You feel lonely and like nobody cares about you, but from what you’re telling me, multiple people have reached out to you in the past week. You mentioned 6 people called you and asked how you were doing. It seems like people do care about you.”

Summarize

Connect emotions to the problem being discussed.
Use diagrams and list of key emotions and problems—provide to the patient as a reference.

Example: A patient wants to address her chronic pain with opiates, but has agreed to work with you in learning more about triggers and possible treatments. You might summarize: “Your pain is very severe, and it’s making it hard for you to do many things, including exercise, sleep, and taking care of your kids. You’re feeling pretty angry, sad, and disappointed. This seems like important stuff to discuss. Can we talk a bit more about how you’re handling all this?”

Enhance Coping

One of the main goals of supportive therapy is to increase patients’ use of healthy coping skills. It is important to explain this concept to patients, and that together, you will be coming up with ways (coping skills) for them to improve their problem, or relieve symptoms. Emphasize that everyone needs ways to manage problems, and healthier coping skills are simply skills that are more effective ways of reaching goals and controlling symptoms.

Start by learning about which coping skills the patient already has. Ask about how they have managed difficult situations in the past. As their provider, you may know of some qualities and strengths they have used to overcome previous conflicts or illnesses. Point these out. The goal is to help them utilize and expand on these to help them cope with the problem at hand.

Because patients usually cannot articulate how they cope, it is important to be able to identify healthy and unhealthy coping skills in the various ways they come up. This requires a bit more understanding about defense mechanisms. Coping skills and “defense mechanisms” are essentially the same thing: they are the way people handle problems. Once you are able to pick out a few of the patient’s coping strategies, you can use your supportive techniques to help them build their healthy skills and decrease their unhealthy coping skills. Because this is such an essential part of supportive therapy, we have included detailed tables at the end of this section. These describe common unhealthy and healthy coping skills, and the scenarios where they are often present. Table 11-1 includes “unhealthy” skills, examples, and tools you can use to develop healthier coping. Table 11-2 includes “healthy” skills, examples, and ways to help the patient to utilize these skills. These tables will be useful for reference throughout your visits with patients.

TABLE 11-1 Unhealthy Coping Skills and Defense Mechanisms

PROBLEM	UNHEALTHY COPING SKILL/DEFENSE	EXAMPLE OF PATIENT RESPONSE	EXAMPLES OF PROVIDER RESPONSE	SUPPORTIVE TOOL USED	HEALTHIER COPING
Frequent readmissions	Denial	“It’s not my fault my blood sugar is so high—I’m doing everything I can. If the pharmacy could remember to fill my insulin, I’d basically be healthy!”	I know it has been tough to manage your diabetes. It is a difficult disease but I think we can do this. What would you like to focus on? How are you managing the stress? Tell me about how you are feeling through this?	Validation Instill hope Problem focus Identifying emotions	Identify a specific goal Identify positives and rewards associated with achieving the goal
Housing issues	Projecting Uncomfortable feeling is believed to come from someone else rather than oneself. (here: anger)	“My sister threw me out onto the streets. She’s just an angry and hateful person. I don’t need her.”	I can see why you might be angry with your sister as well. Do you think that has anything to do with your housing problems? How would you express that feeling to your sister?	Normalizing Problem focus Identifying emotion Role play	Express problems to a friend, a provider hotline, and sister when ready Channel anger: music, art, and activity
Substance abuse	Rationalization	“My wife is so annoying; I have to drink just so I can deal with her!”	It sounds like you and your wife are having some problems, and that you are looking for a way to deal with that. But your drinking is also causing problems, and maybe we can address that first? What else could you do when you feel annoyed with your wife?	Problem focus Summarizing Confrontation Socratic questioning	Support groups (alcoholic anonymous) Alternative hobbies for stress reduction Reducing triggers to drink
Pain	Externalization Problems attributed to others or external factors	“I gained 30 pounds since you stopped my opiates. I can’t move with all this pain. It’s impossible to be healthy now!”	I see your point, but what do you think your role is in all these? What sorts of things have you done to be healthy in the past?	Validation Socratic questioning Identifying coping skills already present	Meditation Deep breathing Exercise/physical therapy