Bedside psychotherapy: Brief and surprisingly effective
A therapeutic alliance often develops within minutes
STEP 3. Select appropriate psychotherapy. The psychiatrist’s challenge is to know:
- when to use which approach
- when to combine approaches
- what problems each approach targets.
A hospitalized medical patient often has a fluctuating course and may require more than one approach—or even a different approach at each visit. Thus, flexibility and creativity are keys to successful bedside psychotherapy.
STEP 4. Integrate psychotherapy with medication, as needed. Consider target symptoms for using psychotropics and how medication may help the patient attain treatment goals. Does the patient require medication to allow psychotherapy to occur?
STEP 5. Combine steps 1 to 4 with a good bedside manner. An empathetic approach will help most patients, no matter which psychotherapy model you use (Box 1).4,8,9
Case continued: First aid for the ego
The C-L psychiatrist diagnosed Ms. T as having acute stress disorder and identified four target symptoms: bereavement, demoralization, anxiety, and hyperarousal. During the initial interview, Ms. T appeared to be psychologically-minded and open to psychiatric intervention.
The psychiatrist considered her at high risk for PTSD and prescribed citalopram, 20 mg/d, because selective serotonin reuptake inhibitors may prevent PTSD. Ms. T was also given clonazepam, 0.25 mg as needed, for severe anxiety.
The psychiatrist visited her 20 to 30 minutes daily. Initial psychotherapy focused on supporting Ms. T’s ego. Resilience-building interviews—using questions to counter feelings of despair, meaninglessness, and sorrow—addressed her demoralization and grief. She regained some sense of meaning and hope by focusing on caring for her other son and on her family’s love. She also found a sense of peace through prayer and by visualizing her lost son safe in God’s hands.
The psychiatrist also taught her relaxation skills to manage her anxiety symptoms. These included abdominal breathing and guided imagery (picturing herself in a safe, comforting place).
- Start by attending to basic physical needs (help the patient get some water or move into a more comfortable position)
- Sit down, even for a brief session
- Smile and touch the patient when appropriate
- Ask “What troubles you most?”
- Inquire about the patient’s experience (ask what the medical illness or treatment was like, not just what happened)
- Look for opportunities to comment on the patient’s strength and accomplishments
- Avoid using confusing medical terms or psychiatric jargon
- Be sensitive to cross-cultural, spiritual, and religious issues, as well as culture-specific health beliefs
Psychotherapeutic options
Three psychotherapeutic approaches are particularly useful at bedside—supportive therapy and resilience-building, cognitive-behavioral therapy (CBT), and psychodynamic therapy.
Supportive therapy and resilience-building is the most common bedside model. Supportive therapy’s goal is to strengthen coping skills, thereby reducing anxiety and enhancing well-being, self-esteem, and function.
Fostering a good working relationship is the first priority.10 The therapist works to contain the patient’s anxiety and provide an “auxiliary ego” to supplement his or her reality testing, planning and judgment, and sense of self.2,10 Supportive techniques include suggestion, clarification, limit-setting, reinforcement, reassurance, and empathic listening.
Much of the work relies on positive transference to build the supportive relationship.8,10 Transference is interpreted only when negative transference disrupts treatment; the therapeutic goal is to decrease the patient’s anxiety. Resilience-building questions (Box 2)4,11 help identify the patient’s skills and competencies and mobilize his or her internal resources.
CBT attempts to identify, challenge, and correct a patient’s inaccurate or dysfunctional beliefs about illness, treatment, or self-image. For example:
- a patient with second-degree burns may be convinced she is the world’s ugliest person
- a patient facing an operation may believe he will be permanently disabled, as was his father after a similar procedure.
CBT can also help dispel beliefs that psychiatric treatment is for “crazy” people.
Behavioral therapy can help patients manage distress related to their medical care, such as shortness of breath while being weaned from a ventilator or arousal and anxiety related to procedures. Techniques that work in office settings—systematic desensitization, in vivo exposure, breathing exercises, progressive muscle relaxation, guided imagery, meditation, and hypnosis—also can be effective at bedside.12
Psychodynamic therapy. Patients can develop insight through psychodynamic therapy, even in brief therapeutic relationships. Useful bedside techniques include clarification, confrontation, and interpretation of behavior, conflict, and transference.
For example, a patient who survived heart surgery later developed depression and suicidal ideation. Psychiatric interview revealed she was experiencing survivor guilt because her mother had died from a heart attack. Emphatic clarification and validation of feelings often can help lift such a patient’s mood and allow a dialogue to begin.
A “psychodynamic life-narrative” approach1 can help treat depression in medically ill patients. The therapist first asks the patient to describe the illness’ meaning in his or her lifespan, then formulates a statement (the “narrative”) of its meaning at the moment. The narrative is intended to:
